RHEUMATISM, GOUT 



SOME ALLIED DISORDERS 



MORRIS LONGSTRETH, M.D. 

ONE OF THE ATTENDING PHYSICIANS OF THE PENNSYLVANIA HOSPITAL; LECTURER ON PATHOLOGICAL 
ANATOMY AT THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, PA. 



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CONTENTS. 



CHAPTER I. 

INTRODUCTORY. 

Rheumatism — Some Considerations Concerning- its History, Nosology, and Etiology — 
Synonyms — Definition pp. 1-7 

CHAPTER II. 

FORMS AND VARIETIES OF RHEUMATISM. 

Its Varieties and their Classification — Its Nomenclature — Reasons for a Change of 
Nomenclature pp. 8-15 

CHAPTER III. 

CAUSES OF RHEUMATISM. 

Causes : Hereditary Predisposition, True and False Heredity ; Age, its Effects on 
the Various Forms ; Sex ; Connection with General Health and other Diseases ; 
Climate, Country, Race, and Change of Habitation ; Seasons, Atmospheric 
and Barometric Influences ; Occupation and Manner of Life ; Temperament 
and Constitution ; Injuries ; Sleep ; Former Attacks and their Effects ■ 
Drugs pp. 16-41 

CHAPTER IY. 

PATHOLOGY. 

The Various Theories: The Local or Inflammatory; the Vascular; the Nervous, 

comprising the Electric, the Spinal, and the Vaso-motor ; the Specific Poison, or 

xctic Acid Theory ; the Physiological and Chemical Origin and Nature of the 

Lactic Acids ; the Defects of this Theory ; the Infection Theory pp. 42-66 



IV CONTENTS. 

CIIAPTEE Y. 

DESCRIPTION AND COURSE OF THE DISEASE. 

Acute Rheumatism : the Prodromal Interval; Chill; Fever; Pain; Aspect of Face; 
General Bodily Condition ; Skin ; Pulse ; Temperature ; Digestive Functions ; 
Urine ; Sleep ; Delirium ; Menstrual Function ; Epistaxis ; Course, Duration, and 
Severity; Result. — Subacute Rheumatism: Its Distinction from other Grades 
and Forms .pp. 67-81 

CHAPTER YL 

CONSIDERATIONS OF THE INDIVIDUAL SYMPTOMS OF ACUTE RHEU- 
MATISM AND THEIR PECULIARITIES. 

Of the Fever ; of the Chill ; Temperature Curve ; Modifications from Complica- 
tions ' pp. 82-87 

CHAPTER YIL 

CONSIDERATIONS OF THE INDIVIDUAL SYMPTOMS OF ACUTE RHEUMA- 
TISM AND THEIR PECULIARITIES.— Continued. 

Of the Joints : Development of the Articular Phenomena ; Reasons for the Involve- 
ment ; Attitude and Position of the Patient and of the Joints ; Cause, Seat, and 
Character of the Pain ; Redness ; Swelling- ; Subsidence of Inflammation ; Tem- 
perature of the Joints ; Comparison with Gout ; Numerical Frequency in the 
Different Joints ; Relation to Cardiac and other Complications ; Duration ; 
Metastasis pp. 88-94 

CHAPTER YIII. 

CONDITION OF THE SKIN AND ITS FUNCTIONS. 

Excess of Function— Sweating and its Significance : Its Frequency ; Its Characteris- 
tics ; The Difference of the Sweats — The Eruptions : Sudamina ; Urticaria ; 
Medicinal Eruptions ; Hemorrhagic Eruptions ; Rheumatic Purpura ; Hemophilia 
or Scurvy ; Embolic Purpura - v . . .pp. 95-100 

CHAPTER IX. 

GENITO-URINARY APPARATUS. 

Question of Rheumatic Localizations in the Kidneys — The Result of Contact with the 
Altered Urine — Comparison with Gout — Albumen, its Significance — Raver's 
Rheumatic Nephritis— Intercurrence of Bright's Disease and Rheumatism — Lan- 



CONTENTS. V 

cereaux's Interstitial Nephritis— Embolism, or Secondary Albuminuria — The 
Bladder, Affection of its Muscular Tissue— Urethra, Ovaries, Uterus, etc.— Rheu- 
matic Orchitis pp. 101-100 



OHAPTEE X. 

THE URINE. 

Causes of its Alterations — Its Amount — Its Color — Its Reaction — Its Density — 
Urea — Uric Acid — Other Solid Ingredients — Albumen — Sugar — " Fibrinous 
Urine." pp. 107-119 



CHAPTER XL 

COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS. 

Their Importance in Rheumatism — The Point of View from which they are to be 
Regarded — The Order and Frequency of their Occurrence : Muscular ; Circula- 
tory ; Respiratory, Cerebro- Spinal, Digestive, and Urino-genital — Cardiac Lo- 
calizations: Our Knowledge of them; Their Frequency; Various Forms of Car- 
diac Lesions Collectively ; Their Relative Frequency and Combination. Time 
of their Occurrence and Concurrence ; Symptoms of Endocarditis ; Symptoms of 
Pericarditis — Rheumatic Localizations in the Vascular System pp. 120-131 

CHAPTER XII. 

COMPLICATIONS, OR EXTRA- ARTICULAR LOCALIZATIONS. — Continued. 

Respiratory Apparatus : The Parts Affected and the Frequency of their Involvement ; 
Pleurisy, its Character and Duration ; Pneumonia, its Relation to the Rheu- 
matic Process ; its Type and Grade ; Mucous Membrane Inflammations, their 
Relationship to the Tissues Ordinarily Affected in Rheumatism ; Rheumatic 
Angina ; Bronchitis and Broncho-Pneumonia — Digestive Apparatus . .132-136 

CHAPTER XIII. 

NERVOUS COMPLICATIONS. 

Symptoms— Acute Inflammatory, Cerebral, and Meningeal Lesions— Cerebral Rheu- 
matism — Hyperpyrexia — Other Nervous Symptoms — Rheumatic Cephalal- 
gia — Vertigo — Conditions which Tend to Produce Cerebral Symptoms and 
Lesions , ,. , .pp. 137-152 



VI CONTENTS. 

CHAPTER XIY. 

MORBID ANATOMY. 

Pathological Changes: Hyperinosis ; Condition of Joints; Changes in Cartilages ; In 
Tissues and Skin ; In the Blood — Hyperpyrexia — Cardiac Conditions — Endocar- 
ditis— Histological Process in Endocarditis— Embolism — Cardiac Murmur — Val- 
vular Vegetations — Inflammatory Products : 1. Inflammatory Resolution ; 2. In- 
fhmmatory Organization — Chronic Endocarditis — Pericarditis — Acute and Chronic 
Myocarditis pp. 153-175 

CHAPTER XY. 

DIAGNOSIS AND PROGNOSIS. 

Diagnosis: Pyaemia; Gonorrhoeal Rheumatism ; Acute Rheumatoid Arthritis ; Acute 
Gout ; Pain ; Ag3 : D\iration of Attack — Prognosis — Death from Violence of the 
Fever ; Death from Cardiac or other Visceral Complications ; Disability from 
Joint Changes ; Liability to Second or Recurring Attacks, or to Chronic Rhenma- 
.tism — Predisposition to the Disease pp. 176-184 



CHAPTER XYI. 

TREATMENT. 

Treatment of Rheumatism in the Past — General Remedies : Venesection ; Cupping 
and Leeching ; Purgatives ; Diuretics ; Sudorifics ; Woollen Applications ; Moist 
Applications ; Revulsives and Counterirrrtants ; Blister Treatment — Drugs 
Colchicum ; Guaiacum ; Cinchona Bark ; Quinine ; Opium ; Antimony and Mer- 
cury ; Veratria and Aconite — Alkaline Treatment : Nitrate of Potash ; Bicarbon- 
ate of Potash ; Citrate of Potash ; Lemon Juice : Bromide of Potash — Salicyl 
Treatment : Salicin ; Salicylic Acid ; Salicylate of Soda — Mode of Action of the 
Salicyl Treatment : Action of Salicin; Action of Salicylic Acid ; Action of Sali- 
cylate of Soda — Anaesthetic and other Topical Applications — Diet and Regi- 
men pp. 185-221 



CHAPTER XYIL 

CHRONIC ARTICULAR RHEUMATISM. 

Symptoms and Course. — Morbid Anatomy. — Diagnosis. — Treatment. —Local Applica- 
tions f pp. 222-239 



CONTENTS. Vll 

CHAPTEE XVIII. 

GONORRHCEAL RHEUMATISM. 

Liability to, and Frequency of its Occurrence— Symptoms, Course, and Duration- 
Its Results— Treatment pp. 340-249 

CHAPTER XIX. 

GOUT. 

Causes and Causal Factors. — Age, Sex, Heredity, Customs, and Nationality. — Vari- 
eties. — Symptoms, Course, and Duration. — Acute Gout, Chronic Gout. — Vis- 
ceral Manifestations. — Pathology and Morbid Anatomy. — Diagnosis. — Prog- 
nosis. — Treatment. — Treatment of the Paroxysm. — Treatment of Chronic 
Gout pp. 250-270 



EHEUMATISM, G-OUT, 



AND 



SOME ALLIED DISORDERS, 



CHAPTER I. 

INTRODUCTORY. 



Rheumatism — Some Considerations Concerning' its History, Nosology, and Etiology — 

Synonyms — Definition. 

The term Rheumatism, in the sense in which it is now used, dates from 
about three centuries ago. Previous to this time writers comprehended 
under the term arthritis this disease with gout and all other inflamma- 
tions of the joints, ligaments, and muscles. Anciently the words rheuma 
and rheumatism denoted all those diseases in which it was supposed that 
the blood became impregnated with acrid humors, phlegm, bile, or other 
noxious materials. Hippocrates states that the bile mingles with the 
blood in the veins and articulations, causing swelling of the joints, or 
extending to the whole body, producing acute pain. In this view, with 
some modifications, Hippocrates was followed by most of the later writers. 
From this group, these writers separated the diseases of the mucous 
membranes under the general head of catarrhs ; all the other members of 
the group retained the designation of rheumata. In 1610, William de 
Baillou published his thesis on rheumatism, in which he showed the dis- 
tinction between this disease and gout. Sydenham, who lived fifty years 
later than Baillou, even more distinctly divided these two diseases. Cul- 
len, Stoll, and Van Swieten in their teachings promoted these views and 
framed their treatment accordingly. The humoral pathology of that day 



RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

, lv to {hv enforcement of these theories of the nature of 

mtftam. Although the separation of these two maladies 

BBtomed, nevertheless the meteorological theories of the 

. m medical writers, assisted by the Nosologists, who at- 

e ;l u knowledge of medical science into such bounds as 

M* to give a name to, contributed to overturn the sound basis 

$ lenham had given to the subject, so that early in the present 

find the two diseases grouped under the same heading, and 

1 upon by many as diverse manifestations of the same humor min- 

iritfa the blood. 

v x si mictions Concerning its History, Nosology, and Etiology, 

In early times, but especially after the separation of rheumatism from 
- that the terms "rheumatism" and "rheumatic" were 
external diseases, or, rather, to maladies which affected the 
trta of the body ; however, it must be admitted that with rheu- 
m were confounded many ailments which were of wholly dissimilar 
• ; for example, phlebitis, pyaemia, neuralgia, coxalgia, certain scor- 
and scrofulous diseases, and even some of the puerperal conditions, 
tli is, so to speak, external nature given to rheumatism, its cause 
•oked upon as of external origin, and the principal cause was con- 
1 to be cold and such atmospheric variations as were connected 
with changes of temperature. This generally accepted theory of the cau- 
i of rheumatism led to the inclusion among the heterogeneous com- 
ponents of this malady other diseases, which formerly were not consid- 
■ -longing to the same group, but which were due to the same 
supposed cause, viz., cold. Thus, all diseases, especially those accompa 
with pain, were counted as rheumatic, if not as being " rheumatism "" 
itself. Many of these newly included diseases were affections of internal 
organs. Rheumatism was, therefore, no longer a disease of the external 
alone, bat also a visceral affection. The brain, the lung and its 
88, the heart, the kidneys, etc., were all supposed to be the 
f rheumatism, and not only the morbid changes which we now 
'■ ■ e organs as the results of rheumatic disease, but many 
ra were ascribed to this humoral poison. A rheumatic apoplexy, a 
•a of the intestines resulting in diarrhoea and dysentery, and 
others were added to this list. Through the advancement made in 



INTRODUCTORY. 3 

"morbid anatomy, aided by greater accuracy in clinical studies, some of 
these diseases have been confirmed in their position as the results of the 
rheumatism poison, others have been thrust away, and still others, hitherto 
unknown, have been brought to light and arranged in a proper relation to 
this morbid cause. 

The position which rheumatism now occupies, as a nosological entity, 
is that of a group of symptoms, not necessarily and essentially connected, 
having a common or supposed common cause, without, however, any, as 
yet discovered, anatomical basis. That this should be the position of 
rheumatism, is the necessary result of varied opinions held concerning it 
from the earliest times until the present. At first the word was used 
like catarrh, to signify a " defluxion of an acrid humor, generated in the 
brain, into various parts of the body," and later, after the catarrhal affec- 
tions of the mucous membrane had been separated into a distinct group, 
denoted all diseases due to the circulation of acrid humors. Later still it 
was employed to denote the vague pains of the external parts, and after- 
ward, when Ballonius distinguished it from gout, rheumatism was applied 
to the same group of symptoms to which it now appertains. It is no won- 
der, therefore, that the term, as handed down to us, has as vague a signifi- 
cance as some of the pain to which it has been and is at present applied. 

While at the present time we may hold more definitely in mind what 
we comprehend under the heading of rheumatism than was done formerly, 
when unquestionably neuralgia, pyaemia, coxalgia, and certain syphilitic 
affections were included in this group, still it must be admitted that the 
acute and chronic forms of rheumatic articular disease and muscular rheu- 
matism form a class which, if not pathologically dissimilar, are nevertheless 
joined together by only one common symptom, viz., pain, and one common 
cause, viz., cold. It is self-evident that these two bases are not sufficient 
grounds for founding either a pathological or an etiological group of disease. 

The cause of this heterogeneous classification, so evidently the result of 
a survival from ancient times, is to be explained partly by the failure of 
post-mortem investigations to disclose any adequate explanation of the 
symptoms, and also by the infrequency of the opportunities to conduct 
such investigations, owing to the rarely fatal character of a vast majority 
of the cases belonging to this group of diseases. Although it is true that 
many patients die from rheumatism, the fatality occurs mostly from the 
after-results of the acute disease, and, therefore, at a period when the 
special manifestations and characteristic lesions have subsided and can no 



4 RHEUMATISM, GOUT, AND ALL1KD DISORDERS. 

« soon in the condition in which they present themselves during 
M the failure from this cause to study the special 
•Ism d068 not seem to cover the whole ground, or to ex- 
..: ignormnoe of the special pathology of this affection, either in 
OX chronic form, or its manifestations as a muscular rheumatism. 
iiom the results obtained from the careful post-mortem examina- 
tion of bodiee dying at the period of the disease most favorable for such 
lies, and the entire inadequacy of the lesions in explaining the morbid 
symptoms, it is not probable that more frequent opportunities for such 
examinations would contribute very greatly to our knowledge of its path- 
ology. The true direction, it would seem, for us to seek enlightenment is 
from a study of the altered condition of the blood. Already some experi- 
mental studies have been made, and very many theories have been put 
forward in relation to the noxious ingredients present, but as yet nothing 
definite has been determined with sufficient positiveness to command the 
universal assent of investigators and the profession ha general. I cannot 
but think that if, at the present time, it were customary as formerly to 
bleed freely every patient suffering from acute rheumatism the amount of 
material thus so abundantly presented for examination would call up some 
one fully fitted to determine the problem. It is blood in the living state 
that is needed ; blood post-mortem, is not in a suitable condition for such 
an investigation. Even blood freshly drawn is so rapid in its alterations 
that the study of it is one of the most difficult tasks in the whole field of 
pathological investigation. Consequently to-day, our knowledge of the 
fluid, both in its normal and pathological conditions, is far behind that 
which we possess in regard to nearly every other organ of the body. 
Quite recently, however, more attention has been given to the study of the 
pathological states of the blood, especially in connection with infective dis- 
ease, and this work has yielded abundant results, which are still to be held 
sub judice. In connection with syphilis and some of the exanthematous 
fevers, peculiar corpuscular elements of low forms of animal or vegetable 
life have been shown to be present with tolerably constant persistency. 
How far the presence of these morbid elements in the blood can be 
looked upon as the essential cause of the diseases with which they have 
been found remains to be proved, and is, in fact, the essence of then- 
pathological signification. In connection with malaria, a disease to which 
rheumatism bears a closer resemblance than to almost any other, except 
gout, in the whole nosological catalogue, a newly discovered fungoid 



INTRODUCTORY. 5 

growth 1 has been shown to be present in the blood both of patients 
and infected animals, and a similar minute organism has been found in the 
soil and air of malarious districts. 

It yet remains for us to find some agent or property which, newly 
formed in the blood under the influence of sufficiently exciting causes, 
leads to the outburst of that train of symptoms which we at present in- 
clude under the head of rheumatism ; and also to show whether it is the 
same agent or product acting within the system that gives rise to both 
the acute and the chronic forms of the disease, as well as to the form in- 
cluded under muscular rheumatism. 

The presence in excess of such an agent as lactic acid in the blood, 
which was at one time supposed to be the materies morbi in rheumatism, 
by no means proves that this material, or any other which may be discov- 
ered, is the essential cause giving rise to the disease. The presence of the 
morbid material may be due to the same cause as the disease itself — may, 
in fact, be only a symptom, may be a result and uot a cause. 

Failing to find any efficient element or basis in the blood itself which 
may be regarded as the cause of the disease, the solid tissue remains as 
yet unsearched with the degree of care which can be called at all thor- 
ough. So far, we have only had the general statement made that the 
articular and fibrous tissues, which are specially implicated in the disease, 
show no evidences, or only very slight ones, of inflammatory or other 
changes. It is not improbable that this field of research, like so many 
other unsearched fields, may yield the most profitable return. 

Finally, the results both of physiological and of pathological experi- 
ments have been as yet untried. As yet no one has suggested a clue to 
the line in which such examinations should be conducted ; but until the 
trial has been made in these various directions, the search for the patho- 
logical relationships of rheumatism must not be abandoned. 

Kheumatism, in all its varieties, as at present classed, is a group of 
maladies founded on an etiological basis. Away from it' have been sepa- 
rated various diseases as rapidly as a firm pathological foundation has 
been discovered for them, and it is an old block from which many pieces 
have been hewn away. How far the remainder is a homogeneous mass 
can only be known when rheumatism itself has been shown to be a con- 
sistent pathological entity, and its pathogeny is discovered. The etiolo- 



1 Bacillus malaria. Klebs and Tommasi-Crudeli, 1879. 



6 i:il BUM ATISM, GOUT, AND ALLIED DISORDERS. 

gical foundation on which it rests at present is a chill, or some atmos- 
pheric influence of cold and moisture. Such influences may be a good 
and surticient 0OU96 for the disease, but it is not a valid reason for classing 
toh a variety of affections, having merely one factor in com- 
pain. The older nomenclature, from which the present one is 
a derivative, or, in truth, the remains, or a survival, was more nearly 
accurate, and certainly more consistent, for it included all the other dis- 
acknowledging the influence of cold as their cause, and likewise 
having the symptom, pain, as at least one of their principal phenomena. 
The separation of these various diseases and their classification under 
different pathological headings has not been altogether logical, and, so far 
as rheumatism is concerned, has not advantaged us. The class rheuma 
might well stand to-day with its subdivisions : pleuritis, pneumonitis, 
mucosae or catarrhalis, and the other "rheumata." All the latter of these 
diseases, as fast and so far as their pathologico-anatomical characteristics 
were known, have been put in proper and consistent groups, and by these 
discoveries our knowledge has been advanced ; but rheumatism still re- 
mains unknown and unclassified, as the residuum of former ignorance. 

While, as has been shown, it is impossible to regard all the diseases 
now described as rheumatism as identical either in their causation or pa- 
thology, it by no means follows that the term is to be rejected from our 
nomenclature. In fact, any attempt to effect its displacement would be 
attended with failure. The efforts which have more recently been made 
by German authors, as well as others in our own language, to designate 
the disease by other titles, have met with but little success, and have not 
tended to advance our clearness of conception or knowledge of the essen- 
tial factors of the malady. Clearly it has not been the change of name 
which has led up to the essential pathology of any of the diseases which 
have been separated from rheumatism. The steps in the process have 
been just the reverse, and a knowledge of their pathology has shown 
many of them to be so diverse from rheumatism, that a change of name 
became imperative. A name so familiar as rheumatism would be difficult, 
indeed, to displace from our language, even were its pathology most fully 
known. The word itself implies no pathological signification, and, there- 
fore, like many terms similarly applied, may be usefully retained. The 
name, cirrhosis, as applied to the liver, formerly meant merely a tawny 
color ; now, however, it signifies the changes which lead in part to the 
production of that coloration, and is applied not only to the liver, but to 



INTRODUCTORY. 7 

various organs — the kidney, lung, etc. The same may be said of apo- 
plexy. And while in respect to both apoplexy and cirrhosis, since their 
morbid anatomy has become fully known, so, in respect to rheumatism, 
the word still lingers in the language ; and, in spite of all discoveries in 
respect to its nature, will continue to remain, just as these other words 
nave so long done. Even in the new German nomenclature, the authors 
have been compelled to retain the word as an adjective ; thus, rheumatic 
polyarthritis or rheumarthritis, chronic rheumatic arthritis, and rheumatic 
myopathy or myalgia but partially displace the term commonly in use. 
This use of the word in its adjective form has, in their view, much to 
recommend it ; and whatever in the future may be discovered in relation 
to rheumatism and its pathology, or however much the term itself may be 
discarded, still the word "rheumatic" could always be maintained with 
advantage, or even extended in its use, as signifying that great group of 
•diseases having certain etiological features in common, and recognized as 
•dependent in their origin on certain external causes, as cold or atmo- 
spheric influences, until, at least, the other various causal factors have 
become known. 

Synonyms. 

The following names have been applied, by various authors, to rheu- 
matism. Thus we find it called arthritis, rheumatismus, acute rheumatism, 
articular rheumatism, rheumatic fever, rheumatic polyarthritis, rheumar- 
iihritis, polyarthritis synovialis, febrile rheumatism of the joints. 

Definition. 

A definition does not add much to our knowledge of a disease, but it 
seems to be demanded, serving as a row of pins on which to attach our 
ideas. 

Kheumatism is a constitutional disease, attended with febrile disturb- 
ance, and with inflammation of structures in and around the joint, and 
often ©f other organs of the body, especially of the connective-tissue 
group. The disease is not infectious. The inflammation does not lead to 
deposit of urate of soda, does not lead to suppuration, and is erratic or 
shifting in character ; by many is regarded as specific or peculiar, but its 
peculiarity is evidenced only by so violent an action leaving so little trace 
Ibehind it 



CHAPTER II. 

FORMS AND VARIETIES OF RHEUMATISM. 

■ad their Classification— Its Nomenclature— Reasons for a Change of 
Nomenclature. 

Forms of Kheumatism. 

»U8, from what has been said of the history of the disease, that 

tions between the various forms of the disease and the signifi- 

• iched to the various symptoms have been estimated very differ- 

a different times. Among the older writers very many conditions 

held to be rheumatism, or a catarrh, a "denuxion of an acrid 

humor, generated in the brain, into various parts of the body." They 

were not speaking, however, as we do, of a distinct disease, and the forms 

of rheumatism enumerated by them must be considered as a multitude of 

classed under one head. 

The teachings of humoral pathology, with its acrid humors, even later 

still confused a variety of disorders under the general term rheumata, and 

it is not until still more recent times that one cause or one humor be- 

identined with one disease which included only such manifestations 

Id to be rheumatic. 

When the Immoral view of the origin of the rheumatic symptoms be- 

common or was abandoned, their cause was attributed to a 

la of the blood and especially of the tissue involved in the diseased 

Both of these views required and received a special classification, 

the one according to the kind of humor which was supposed to be present 

: the disease, the other according to phenomena which the 

ia entailed and the effects which it produced, or, speaking 

of modern morbid anatomy, of its pathological changes. 

Bin which the influence of cold or "catching cold" could 

ramed to have preceded the painful symptoms, was classed 

m or rheumatic, and an endless confusion in nomenclature 



FORMS AND VARIETIES OF RHEUMATISM. tf 

resulted. It will be perceived that this is a very different assumption 
from that of the older school of humoral pathology. At both times and 
by both sets of writers very many different diseases, having a very varied 
pathology, were confused under one heading, but by the older writers they 
were all regarded as one disease dependent on the same humoral vice, 
while by later writers they were seen to be different diseases character- 
ized by numerous unlike changes, but produced by the same causes. 

This may be termed the "causal classification " and the only things 
which rheumatism of varied forms had in common were an identical 
cause, viz., cold and the general symptom of pain. The humor which on 
the one hand was developed by cold, and on the other hand produced the 
pain symptom, might, so far as their teachings go, be single or multiple. 
The effect the dyscrasic or solidism pathology had on the teachings of 
the causal school, was a demand for the classification of the forms of 
rheumatism, according to the tissue or organ affected. Following the 
writers who advanced these views, rheumatism formed a family of dis- 
eases, separated into forms or species according to the tissue or organ 
involved, and required a different means of treatment accordingly. 

The various views of inflammation have exercised their influence in the 
classification of rheumatism, and when all diseases were regarded as in- 
flammatory in their nature, the many forms of rheumatic disease were 
grouped according to the grade of the inflammatory process. Thus we 
find hyper- and hypo-sthenic and asthenic rheumatism. Since the time 
of Scudamore, the forms of rheumatism which he proposed and which 
probably have nearly the same significance as those just given, have to a 
great degree held their position until the present time. Scudamore in- 
cluded several painful affections of the nerves among rheumatic diseases, 
which are no longer recognized as of this nature, and although he speaks 
of the muscular form of the disease, did not separate it into a class by 
itself, as has been more recently done. 

As has already been said, Ballonius first used the word rheumatism, in 
the sense now intended, for pains in the joints and muscles, and dis- 
tinguished them from gout, which had previously been confounded with 
them as a general arthritic affection. However, since then even until 
now many vague pains, as well as some of another character unquestion- 
ably, have been called rheumatic, and while the settlement of the question 
of the more characteristic forms of rheumatic disease and their differenti- 
ation from diseases having symptoms of a more or less similar character 



UttSB, &OtJ^ alTO ALLIED DISORDERS. 

, :1 sn matter, oven supposing the cause of the malady 

,*„. lint as wo depart from this group of forms, the dis- 

, manvva-uo pains ami set of symptoms truly rheumatic 

, different order becomes, almost progressively, more and 

difficult ami uncertain that many recent observers, 

« faraway from the probable truth as did the older writers in 

:nm by including every pain as rheumatic, are inclined to 

limit the bounds of rheumatism to the acute and chronic articular affec- 

- and include everything which has heretofore been joined to this 

disposition to effect the separation is shown as much by this as 

statement, that names are applied to these other affections 

from which the word rheumatic is omitted. 



Its Varieties and their Classification. 

There lias been, both in earlier times and recently, a tendency ex- 

1 to change the names and classification of the well-recognized forms 

of rheumatism, in accordance with the prevailing view of the nature and 

cause of the malady. At one time it was regarded as a general 

or infectious disease, at another as a fever, and again merely as a peculiar 

inflammation of the joints and other structures. 

S idamore divided rheumatism into three forms: acute, chronic, and 
lie, the latter intermediate in its symptoms "between the high 
tutional fever of the one and the absence of fever of the chronic." 
iel pointed out the order — the muscular, the articular, and the vis- 
with numerous sub-orders, according to the locality and the activity 
of the symptoms. Fuller proposes four divisions of the disease, viz., acute 
ii, rheumatic gout (differing from both rheumatism and gout), 
chronic rheumatism, and neuralgic rheumatism. What may be accepted 
German classification, as given by Senator, in "Ziemssen's 
i." is that of rheumatic polyarthritis or rheumarthritis, essen- 
■ constitutional disease ; chronic rheumatic arthritis and rheumatic 
or myalgia, affections of a local nature. Hueter calls rheuma- 
rthritis synovialis, and divides it into acute and chronic, while 
rthritic affections, though included in this title, are designated 
indicating their cause, for example, pyemic, gonorrhceal, etc. 
litrv, as well as in England, rheumatic fever has been a common 
[nation for acute rheumatism, but has not found general acceptance ; 



FORMS AND VARIETIES OF RHEUMATISM. 11 

the objection which has been offered to this term is that it implies an in- 
fectious disease similar to the general class of fevers, while on the other 
band this has been contended to be the more correct designation, because 
in this form of the disease, the pyrexia is the chief factor as distinguished 
from the joint trouble ; in other words, that the fever produces the joint 
affection rather than joint involvement the fever. 

Senator contends for the employment of the adjective " rheumatic," as 
more logical and consistent with our deficient knowledge of the pathology 
of the disease, and that " rheumatism " cannot be maintained in a noso- 
logical category and is "not merely superfluous but positively detri- 
mental." 



Its Nomenclature. 

While all writers are not agreed on, and some do not believe in, any 
one underlying pathological entity as the cause of the various forms 
of this disease, still, so long as no certain basis of causation is discover- 
able, I do not believe it is possible to alter the nomenclature of the rheu- 
matic affections and to obtain common concurrence to a new division of 
its forms. Neither do I think that the attachment of new names to the 
•old forms is of any great advantage, unless perhaps it can be shown that 
such a change will alter the current of medical thought and investigation. 
If a change of name would suffice to disabuse the mind of the crude 
notions of the ancient humoral pathology, or lead us to think of rheuma- 
tism as something tha£ is not merely synonymous with "cold," every one 
would gladly consent to the removal of the old landmark according to 
which our thoughts have been for ages directed. The confusion neces- 
sarily attendant upon such changes, while temporarily inconvenient, is 
willingly and gladly submitted to whenever the exact nature or cause of 
,a malady, formerly confounded with something else of a similar character, 
is pointed out. Our ideas cluster in new groups around another set of 
phenomena and their cause, and thus the advancement of scientific medi- 
cine is promoted. Whether this will be the result of the efforts of the 
German observers, who propose new names for the chief of the rheumatic 
diseases — as has already happened for various ones of the lesser grades 
•of this disease, for example, neuralgia, some forms of sciatica, and rheu- 
matoid arthritis — remains to be seen. 

.Still, I do not think that even the most radical change of names yet 



|3 RHBUMAH8M, GOUT, AND ALLIED DISORDERS. 

oi any marked results. Hueter's proposed divi- 

D an anatomico-pathological basis, while it is by 

f ; ir more accurate, and perhaps more scientific than any previous classifi- 

iily not sufficiently comprehensive to include all the phe- 

• .1 whkh we think of as rheumatism ; neither does it have the merit 
which, as already said, is the only one which any change of names can 
possess — save the one founded on the yet undiscovered exact cause — of 

• ing our thoughts into a new pathological channel. To speak of rheu- 
matism as a synovitis is, it would seem, a step backward rather than for- 
ward in our general notions of its pathology, and it is also difficult to con- 
ceive wherein there is any gain, except from a purely morbid anatomical 

•. id classing gout, rheumatoid arthritis or arthritis deformans, gon- 
orrheal and syphilitic rheumatism, as well as chronic and acute rheuma- 
tism, under one heading. Polyarthritis synovialis acuta and chronica, and 
those occurring in the venereal subject, poly-panarthritis, and panarthritis 
are not any more distinctive as names than those, so long familiar, 
for which they have been substituted. We do not wish to see gout 
classed again with rheumatism, from which it has been separated. Eheu- 
matoid arthritis has too lately been placed on a separate basis for us to 
think of its re-alliance with chronic rheumatism with satisfaction. Gonor- 
rhoea! affections of the joints, too, have been shown to have probably a 
septicemic origin, and the name of rheumatism, with which they have 
nothing in common except locality, ought never again to be joined to 
them, or the two diseases to form parts of one class. 

Reasons for a Change of Nomenclature. 

Until there is some improvement offered, it would seem best to adhere 
to the classification already in use and so generally accepted. 

Acute rheumatism forms a thoroughly well-understood class of symp- 
toms, of which, perhaps, it may be claimed that the nature and cause, or 
causes, are not definitely known, yet it immediately calls to mind a dis- 
tinctive picture of disease. The distinctions of acute and chronic imply 
two things, viz., the duration of the malady, and the activity of the symp- 
toms or of the morbid process. The acute form is always characterized 
eater or less activity, and usually, though not always, this activity is 
of short duration ; while, on the other hand, the chronic form is slow in 
•pment and changes, and long in duration, though not always so. 



FORMS AND VARIETIES OF RHEUMATISM. ]',', 

By many writers the word articular is added to the name of the disease, 
jet, I think, without advantage. All who believe that rheumatism is an 
.articular disease, do so quite rightly ; but such a designation would Beem 
to detract from its general or constitutional characters. If it is intended 
merely to call attention to the common feature of the disease or the spe- 
cial phenomena of individual cases, the title is beyond criticism. It must 
be remembered, that among both acute and chronic cases of rheumatism 
there are, especially of the latter, instances in which the articular symp- 
toms do not bear emphasizing, and appear as subordinate phenomena of 
the attack. The number of such cases may not be numerous; still, in 
this disease, which is so pre-eminently, nay, almost universally, a joint 
disease, they do occur, and should receive due attention in the nomencla- 
ture of the malady. Much less proper is the name — more recently ap- 
plied by German authors— of polyarthritis ; the number of the joints 
affected is not an essential feature of the disease, and, while it is exceed- 
ingly rare to see a case, especially of acute rheumatism, in which a single 
joint is attacked, chronic rheumatism affords very numerous examples of 
monarthritis. Senator, in his classification, pays deference to this differ- 
ence, and distinguishes acute rheumatism as a polyarthritis, and chronic 
rheumatism as simply a chronic rheumatic arthritis, but Hueter applies 
polyarthritis to both forms. 

Acute rheumatism is a constitutional disease, attended with fever, pain 
in various parts of the body, and almost invariably in several joints, in 
and around which evidences of inflammation and exudation are commonly 
present. The joint symptoms are often peculiar, fugitive, and erratic, but 
never result in suppuration or the deposit of sodium urate. The internal 
organs are affected often by inflammatory changes, especially the endo* 
cardium and the serous membrane. 

Subacute rheumatism is a milder form of the disease, but is essentially 
the same affection ; there is little or no fever, usually fewer joints are 
affected, and the symptoms in connection with them are less intense ; the 
general vague pains of the muscles are usually present in this form, and 
are more marked, or, at least, more noticed, than in the acute form. The 
division into the acute and subacute forms is made for the sake of conve- 
nience of distinction, and does not indicate any essential differences be- 
tween the two, except as to the grade of severity. 

By some writers, subacute rheumatism, as I have defined it, has been 
confounded with the chronic form of the disease. To do this seems to 



[4 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

justifiable ; subacute rheumatism, in respect to the age and class of 

'•icnts. the circumstances which seem to produce it, as well as its 

course, although its Juration may be more prolonged, exhibits a great 

irity oi typo to that of the acute form. As has already been said, 

• rheumatism is not only of long duration, but its symptoms are of 

an inactive character throughout ; it is conspicuously attended by changes 

in ami about the joints, which are of a progressively increasing tendency 

: a permanent character. Subacute rheumatism may originate an 

involvement of internal organs in organic changes ; chronic rheumatism 

probably never develops them. 

We may define chronic rheumatism — a disease so unlike in type the 
other forms of rheumatism, that many are inclined to regard it as a dif- 
ferent morbid process— as a collection of symptoms, having, so far as 
known, almost only one phenomenon in common with the other forms, 
viz. , the pain about the joints. It is unattended with fever, or this symp- 
tom is so slight that the increase of bodily heat is probably due to the 
pains present in the aggravated cases. There is no evidence of acute 
inflammation of the joints or their annexa, or of the other locomotory ap- 
paratus ; but there is more or less constant pain of these parts, aggra- 
vated, or, perhaps, only produced by motion, and there is a very marked 
tendency to the production of various anatomical alterations of these 
parts, progressively increased the longer the disease lasts. It is a disease 
of the decline of life, frequently is consecutive to acute rheumatism, but 
very frequently appears without relation to the acute disease, is nearly 
perennial, its symptoms or effects are everlasting in the person attacked, 
and some of its phenomena are usually more or less accentuated by 
changes of weather or barometric pressure. 

Some writers describe the chronic variety as composed of cases with- 
out active symptoms— i.e., the milder cases of subacute rheumatism— and 
others combine with these nearly all the muscular and nerve pains (ex- 
cluding the neuralgias) as well as those here denned. I think it is impor- 
tant to exclude these forms so far as possible, and consider only such 
as are chronic in both respects, viz., as to duration and as to activity 
of symptoms. It would be very desirable, for the purposes of classifica- 
tion merely, if it were possible, to form a class of chronic rheumatism 
in which the main feature is the joint changes, although we rarely 
find such cases unattended with pretty constant muscular pains. These 
I, then, would, as a class, form a parallel with, the main bulk of rheu- 



FORMS AND VARIETIES OF RHEUMATISM. 13. 

matic affections, viz., the articular rheumatisms, the one being chronic, 
the other acute. 

For the purpose of naming or classifying' the rheumatic affections, a 
large number of authors have formed a group for muscular rheumatisnv 
As has already just been said, many writers class this form of the disease 
with chronic rheumatism ; there are cases, however, of muscular rheuma- 
tism which, I think, belong to acute rheumatism, and are as truly in- 
stances of rheumatic fever as the articular cases.. This, point has already 
been alluded to in objecting to the name,, acute articular rheumatism as. 
the heading for the bulk of the cases of rheumatic- fever or acute rheuma- 
tism. Many, if not all, of the cases of so-caUed neuralgic rheumatism,. 
I think, should be included among the muscular rheumatism. This 
variety is also called rheumatic myopathy or myalgia, and authors have 
described under it lumbago, as well as pains of this character occurring 
in other muscle-groups under special names. 

It will be seen at once that, as soon as we pass, beyond the confines of 
the group in which the rheumatic disease is attended with fever and a few 
special symptoms and complications, the classification becomes one of 
merest choice or whim, and is solely dictated by convenience of naming 
or pointing out special phenomena. The line of demarcation between the 
forms of the disease in all the remaining groups is a very faint one, and is 
at one time overstepped, by one symptom, again by another, which has 
been held to as defining the group to which; the individual cases belong. 
Thus, a case of chronic, or even muscular, rheumatism, by a slight aggra- 
vation of its symptoms, or the development of new ones, may be looked 
upon as a subacute case. 

It is unquestionably true that many cases, regarded, as rheumatic, espe- 
cially those of chronic rheumatism, are of an entirely different nature. 
So long, too, as we are uncertain, or for the most part wholly ignorant of 
the nature of the acute form of the disease, it is manifestly unfair to at- 
tempt to be positive concerning what now are looked upon and described 
as its less marked manifestations. And in speaking of forms and varie- 
ties of the disease, we should disabuse our minds of the idea that the 
same essential malady is implied by these terms. The names and classi- 
fication are useful, and even necessary, for the purposes of studying the 
phenomena of disease ; but as rapidly as true pathological entities become; 
known, they are gladly removed to a separate and appropriate class,. 



CHAPTEK III. 

CAUSES OF RHEUMATISM. 

: Hereditary Predisposition, True and False Heredity ; Age, its Effects on 
the Various Forms ; Sex ; Connection with General Health and other Diseases ; 
Climate, Country, Race, and Change of Habitation; Seasons, Atmospheric 
and Barometric Influences ; Occupation and Manner of Life ; Temperament and 
Constitution ; Injuries ; Sleep ; Former Attacks and their Effects ; Drugs. 

Causes. 

The wide-spread occurrence and the varied forms, of rheumatism indi- 
cate that the cause of the disease must be a very generally prevailing one, 
and that the conditions under which it is produced are equally varied. 
The uncertainty of its cause, in addition to the defective knowledge of its 
time pathological condition, is one of the reasons why so many, and prob- 
ably, dissimilar morbid processes have been included under the term 
rheumatism. It does not necessarily result that because the forms of the 
disease are varied a different cause is acting to produce them ; the same 
cause under different circumstances, both internal and external to the 
individual, can result in varied phenomena. The conclusion that the 
cause is a general one because of the frequent occurrence of a single form, 
as well as all forms of the disease, cannot, however, be escaped. That the 
cause or the causes which produce the multifarious train of symptoms 
included under the head of rheumatism are varied ones, must, I think, be 
concluded, partly from the very variety in the symptoms and partly from 
the different circumstances under which the disease occurs. 

Hereditary Predisposition, True and False Heredity. — One of the many 
circumstances included and generally spoken of under the causation of 
rheumatism is the hereditary predisposition. Naturally, statistical methods 
have been brought into use to substantiate this condition and relationship, 
but, as is self-evident, so long as both the cause and the pathological con- 
dition of the disease remain unknown, such methods of proof remain un- 



CAUSES OF RHEUMATISM. 17 

fruitful. The most that statistics are capable of showing is that the dis- 
ease recurs in families in a certain percentage of the members. No 
amount of statistics would make us believe that malaria is an hereditary 
complaint, or that small-pox in the family of a pest-hospital steward is 
transmitted from father to son. On the other hand, disease may be dis- 
tinctly hereditary in its nature, yet the number of cases resulting from 
this cause may form a small proportion of the whole. Disease is trans- 
mitted by heredity with varied intensity in different maladies, and under 
dissimilar circumstances in the same malady. Similarities in the mode of 
life and the surrounding circumstances may frequently so impress them- 
selves on the individual that a false likeness to hereditary transmission is 
given. The notion is common, not infrequently, in some secluded com- 
munities, that fevers, especially typhoid, are prevalent and fatal in certain 
families, whereas the cause of their occurrence, now so well known for 
this type of fever, is to be traced to defective sanitary conditions. Before 
the knowledge of the mode of propagation of typhoid fever, a prevalent 
disease of rural life, became diffused, we were in the same relation to the 
question of hereditary transmission of this disease in which we now are in 
respect to rheumatism. 

In ancient times, when the rheumatic affections, so called, presented a 
confused jumbling of many dissimilar and distinct diseases, the question 
of their hereditary transmission was one little adverted to or discussed. 
Later the existence of hereditary structure was assumed as an occasional 
predisposing cause of rheumatism, although the authors of that period 
regarded its occurrence from this cause as an inference to be drawn only 
from general reasoning, and not from a positive demonstration of the fact. 
Similar circumstances of climate, local situation, and mode of life were 
considered more powerful in their action in the production of it in the 
members of the same family than its transmission by blood relationship. 
It was pointed out that individuals of a family subject to rheumatism 
escaped the supposed family taint by removal of their place of abode or 
by changes of habit. 

It is only quite recently — since the introduction of the statistical methods 
of study, often so vicious in their results and rarely conclusive by them- 
selves — that a strong predisposing hereditary tendency has been claimed. 
This belief can, I think, be traced in its origin to tradition, handed down 
as a common saying rather than to any accurate observations; at least, 
this is true in a great measure of the origin of the belief. It probably 



]> Klll-TMATISM, GOUT, AND ALLIED DISORDERS. 

I id earlier times, when a clear distinction and separation was not 
i een rheumatism and gout. Chomel was among the first to de- 
velop strongly the fact of its supposed hereditary nature, in his "Clinique 

de '* (1837), although he does not mention this predisposition in his 
earlier P&»« sor le Ehumatisme." Apparently it was not until he came 

ly -out with rheumatism that this relationship of the disease was de- 

1 by him. Fuller 1 fully develops his belief by the statistical meth- 
:' the hereditary nature of the disease. Among the patients admitted 
to St George's Hospital he found an inherited predisposition in twenty- 
nine per cent, of the cases; among those in the Hospital for Consumptives, 
twenty-four per cent. ; among the insane, thirteen per cent. Chomel states 
the number at one-half the cases ; and Garrod at one-fourth. Many others 
who unquestionably confounded gout with rheumatism, repeat the state- 
ment of Chomel and are firmly convinced of its hereditary nature. 

All observers, however, who not merely quoting the opinions of others, 
have investigated the question for themselves, have not clearly distin- 
guished the essentials of hereditary transmission or the nature of heredity. 
There is a physiological heredity, the full expression of whose nature is 
seen exemplified in the congenital forms of syphilis, and from this strongly 
marked and high grade of development we find the hereditary taint in other 
affections exhibiting a less and less influence until its effects are scarcely 
traceable. And there is a statistical heredity, the only proof of whose exist- 
ence consists in figures. If the proportion of cases of the disease occurring 
first in the parent and recurring in the offspring is nearly equal to the whole 
number of cases, the likelihood — nay, almost certainty — of its hereditary 
nature becomes nearly positive, and if, in addition, we know the character 
of the malady is such as not to render it improbable, or is, in the first 
instance, of an infectious quality, the matter becomes one almost of dem- 
onstration. The further the facts and conditions depart from this stand- 
ard the less certain must become our assurance of the hereditary nature 
of any disease. That a rheumatic parent's child suffers from rheumatism, 
by no means confirms absolutely the hereditary character of the malady ; 
neither does the escape of the offspring in any given number of instances 
disprove with any certainty the possibility of its hereditary transmission. 

The determination of the hereditary nature of a disease, especially the 
proof of the negative proposition, is a matter of great difficulty, but I 



• On Rheumatism, Rheumatic Gout, and Sciatica, 3d ed., 1860, p. 31 et seq. 



CAUSES OF EHEUMATISM. 19 

think it will be found that a very much larger number of people whose 
parents suffered from it escape rheumatic affections than become rheu- 
matic themselves, and I believe the converse of the proposition is also true. 
Thus, so far as the numerical facts of the case are concerned, the showing 
is uncertain and indefinite, and, until the nature of the malady is better 
known, must remain so. To know that a certain proportion of the off- 
spring of rheumatic parents become themselves rheumatic — at least so 
long as the total of the one falls short of the whole number — is not an 
item of information of any special value, either in the prognosis, diagnosis, 
pathology, or treatment of the disease, and it certainly does not go to the 
settlement of the question of the hereditary, the true physiologically 
hereditary nature of the complaint. 

On the question of the greater or less strength of the supposed hered- 
itary tendency of rheumatism, the unsupported opinion of most writers is 
that there exists a strong hereditary tendency in its development. The 
popular notion is likewise to the same effect. And these two concurrent 
opinions can be called in question only on two grounds : first, a lack of 
evidence or an insufficiency in the number of cases in which the supposed 
tendency is exhibited, by which it appears that, at most, if such a tendency 
exists, it shows itself in but a low degree ; second, a failure from any 
cause to apprehend correctly the nature of an hereditary taint or trans- 
mission. 

Now I have no records of my own with which to substantiate or to 
disprove the correctness of the law of transmission. In my earlier notes 
of cases the matter was carefully inquired into, but later the inquiry has 
been abandoned, partly from my alteration of views in relation to the 
hereditary transmission of diseases in general ; partly from it becoming 
obvious to me that, at least among hospital and out-patient cases, the 
replies were incorrect or confused, and partly because I found that in- 
quiries as to hereditary diseases in general developed the fact that rheu- 
matism in the parent was quite as often absent in the offspring as present. 

That the disease is not strongly hereditary, or at least physiologically 
hereditary, in the same sense as syphilis and tubercle, in its narrower 
sense, is, I think, strongly indicated from the facts which will be discussed 
later, viz. : the age at which the malady develops itself with greatest fre- 
quency. Tubercle and syphilis, traced to an hereditary or congenital 
origin, do not lie dormant in the child ; if they do not manifest themselves 
at birth, a very few months, at the most, serve to give rise to their most 



20 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

frightful phenomena. Cases of tubercle occurring in early adult life, in 
children of tuberculous parents, are open to more than a suspicion of 
having originated de novo, rather than tracing their causation to heredity, 
for we know of so many causes which are capable of grafting a tubercular 
disease on a perfectly healthy stock ; much more then is this likely to 
happen in a child whose vitality is vitiated by the ill -health of its parents. 
No one, of course, argues that a young man, previously healthy, who ex- 
hibits manifestations of syphilis at the age of eighteen years, inherits 
syphilis, because his father suffered from syphilitic disease at a similar 
age, or even if he was tainted at the time of the child's procreation. And 
yet we are called upon to believe in the hereditary nature of rheumatism 
on very similar evidence. 

The reason of our disbelief in the hereditary nature of such a case of 
syphilis is that we know both the cause and the nature of the venereal 
infinitely more closely than the rheumatic disease. We do not need an 
array of figures to substantiate the proposition, and even if statistics 
showed that every son had syphilis at this age — and consequently every 
father, and it approaches lamentably close to it — no one with the sense of 
reason properly trained could be made to believe that syphilis, under these 
circumstances, was hereditarily transmitted, although nothing can be 
more certain, unfortunately, than the facility of its hereditary transmission. 
The same may be true of rheumatism, and yet, so far as our knowledge of 
its cause and its nature affords light on the subject, we are not in a posi- 
tion to either affirm or deny to it this tendency. 

The histories of families, even many instances within my own knowl- 
edge, afford as numerous examples of the failure in transmission as the 
reverse, and it would be just as unfair to argue its non-transmissibility 
from this fact as to attempt to affirm its opposite character from similar 
facts. There exists a much greater difficulty in an attempt to prove a 
negative, and there dwells a strong tendency in the human mind to con- 
clude an affirmative from a purely numerical basis. We constantly jump 
at conclusions from a ratio, whilst the true basis for the decision of the 
question rests on the ground of cause and effect, which, in respect to 
rheumatism, is as yet unknown. 

The question needs to be studied by methods as yet unused for its 
decision. Hitherto its hereditary tendency has been concluded by collect- 
ing the answers of a set of people who, as a rule, are ignorant, unobserv- 
ing, and perhaps prejudiced in favor of the one view of the question, and 



CAUSES OF RHEUMATISM. '21 

who, to increase the magnitude of their suffering, are capable of wilfully 
distorting facts. It is not surprising, therefore, that sufficient evidence 
has been collected to produce a strong impression in favor of the hereditary 
character of rheumatism. I believe there would be a very different show- 
ing produced, supposing that the statistical method of proof has any con- 
siderable value in deciding the question, if we were to ascertain how many 
descendants of rheumatic patients escaped the disease, or determined how 
many of those patients, now classed as rheumatic by heredity, were born 
prior to their parents suffering from the disease. And while I believe 
that such inquiries would show a different result, or would change our 
opinions from what are at present held, I do not think we should be any 
more certain of the true characteristic of rheumatism in this respect than 
we are at present. Such an inquiry involves an immense amount of labor, 
and from the lack of knowledge of a large number of patients, could only 
be made to cover the ground but very partially. 

Without spreading our labor over a large field, likely, at best, to yield 
a barren result, another method, much more accurate and definite, presents 
itself for trial. Let there be a careful inquiry made of the life history of 
offspring procreated at or shortly after the time either parent suffered 
from rheumatism, and before the rheumatic poison or taint can be sup- 
posed to be lost ; if such records can be compared with brothers or sisters 
born previous to or long subsequent to a single outbreak of rheumatic 
disease in the parent, great value will be added to the etiological history. 
A few such instances are of more value than a century's record of thou- 
sands of hospital patients. Great force would be given by every case in 
which the child was reared in circumstances as unlike those of the parents, 
both in respect to climatic influences, locality, and mode of life, providing, 
of course, that these circumstances were not more favoring to what we 
now look upon as productive of the disease. Such observations, to acquire 
a positive value, would require two or three generations for their comple- 
tion, and vague or general recollections cannot be accepted as of any value, 
for the whole question depends on time, and time limited within a few 
months with great precision, for which no memory possesses the requisite; 
accuracy. 

The number of instances of such a concurrence of circumstances and 
of disease, in the experience of any one observer, must necessarily be very 
limited. The limitation results from many causes, two of which are 
especially controlling in their influence : firstly, a rheumatic attack of such 



22 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

force as can carry with it an undoubted power of infection, whatever its 
nature may be, is of short duration ; and secondly, the concomitant phe- 
nomena and symptoms of rheumatism are distinctly unfavorable to the 
consummation of the procreative act. In both of these respects, therefore, 
rheumatism differs in a striking manner from both tubercle and syphilis, 
which, while they may be no more chronic in their duration, yet during 
their chronicity exhibit such active and, in this relation, therefore, force- 
ful phenomena, sufficient for us to presuppose a more potent influence for 
their transmission than in rheumatism during its chronic stages. A few 
instances of the transmission of a rheumatic taint under the circumstances 
here supposed would not only serve to confirm, in the strongest manner, 
its heredity, but would afford a flood of light as to its nature — a much 
stronger light than the present vague notions now held have furnished to 
the consciousness of a careful and thoughtful observer. 

Age: its Effects on the Various Forms. — It is generally stated that age 
is an important circumstance in the occurrence or causation of rheuma- 
tism, and the limitation at which this factor begins or ceases to act are 
variously stated by different observers. In respect to the occurrence of 
rheumatic fever or acute rheumatism (polyarthritis), the limits within 
which first attacks are most frequently seen have been pretty accurately 
studied ; and in this form of the disease the first half of life exhibits the 
most frequent instances. To the chronic form of the disease the last span 
of life is especially liable and is the favorite period. 
» Only one case of acute rheumatism has been recorded under the age 
of one month, and instances of the form of the disease in children less 
than four years of age are so rare and unexpected that their diagnosis is 
one of difficulty, and they are to be viewed with suspicion and carefully to 
be differentiated from other forms of joint disease, as well as from other 
diseases in which joint affections may arise as a complication. At the 
other extreme of life, the instances of first attacks of acute rheumatism 
become equally rare, although the uncertainty in respect to their nature, 
when they do occur, is much less than in early childhood. Among the 
older authors the years within which acute articular rheumatism was 
stated to occur were extended much beyond the period in which they are 
now recognized, and while it is probable this difference in the observa- 
tions is due to some extent to an altered mode of life in more recent times 
which have lessened the liabilities to such attacks, yet much more is to be 
attributed to a more perfect recognition of the disease. 



CAUSES OF RHEUMATISM. 23 

Many diseases have latterly been recognized to have a different 
character and have been placed in separate categories ; this is especially 
true of certain diseases occurring in the early period of life. Syphilitic 
and pyasmie joint and bone affections and also many instances of gout have 
become known in their true characters and have been partitioned off from 
the rheumatic diseases. This recognition has removed many instances of 
other diseases from this class, not only at the two extreme periods of life, 
but likewise from among those coming during more favored periods for 
the occurrence of the disease. 

From five years to seventy was formerly stated as the period within 
which acute articular rheumatism occurred ; but certainly the instances 
of first attacks, or indeed any acute attack, after the age of fifty must be 
extremely rare. The period from puberty to thirty or thirty-five years 
shows by far the largest number of cases. 

How far age, as directly expressive of bodily states and the state of the 
tissues and functions of the organs, is a true cause of acute rheumatism 
must certainly remain in doubt from the uncertain nature of the actual 
eause which occasions and the pathological change which accompanies this 
disease. In childhood, there are certain maladies which are directly to 
be attributed to the condition of the tissues and their functional activity, 
or at least to the short elapse of time since their foetal condition showed 
them to be in another state. Thus, the epithelium of the lung alveoli are di- 
rectly disposed to catarrhal inflammation in early childhood for this reason, 
and here age is a direct cause of the catarrhal pneumonia of children ; yet by 
far the larger number of cases of catarrhal inflammation are found in adult 
life, at a period at least sufficiently removed from the developmental stage 
of the lung tissue, so that the latter must be supposed to have lost com- 
pletely its embryonic tendency. The catarrhal inflammation of adult life 
it) due, then, not so much to the age of the subject, so far as tissue is di- 
rectly influenced by its age or period of development, as to incidental 
causes connected with the mode of life, occupation, and natural exposure 
of the person. 

Further, as has already been expressed in speaking of the hereditary 
tendency of this disease, while we not unfrequently see mothers suffering 
from rheumatism shortly before the period of conception, and therefore 
especially liable or able to convey to their offspring a rheumatic tendency, 
we do not find that rheumatism is frequent in the early years of life. It 
is not until later, after the habits of the child have changed to the more 



24 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

severe and exposing surroundings of adult life, that rheumatism becomes 
a frequent disease. Therefore, acute rheumatism is in all probability not 
only not hereditary, as has been said, but not directly caused by age as 
such, but to the incidental facts of a different period of life. It beccmes 
a question whether acute rheumatism would not be of equally frequent 
occurrence in early childhood as it is in early adult life, if children lived 
as their older brothers live. I do not wish to be understood as referring 
merely to the exposure incident to adult life as productive of a greater 
frequency of the disease ; it is necessary to include with the difference in 
clothing, outdoor life, and exposure, the equally important factors of harder 
work, different food, mental or other nervous strain, as well as other 
differences of function present at the different periods. 

If children, and old people as well, invariably live and act differently 
from young adults, certainly in one sense age may be looked upon as a 
cause of acute rheumatism, and the determination of the efficacy of age in 
its production might become a matter of importance in a diagnostic point 
of view, if not also in our methods of prevention, as so frequently occurs 
in other diseases ; but certainly the diagnosis is clear enough in these re- 
spects without this aid. 

Neither can age as the cause of the production or the reverse be 
brought in question here as in reference to many other diseases — for ex- 
ample, the exanthemata of childhood. The rheumatic diseases are not 
absent from any period of life because one attack has lessened the sus- 
ceptibility to a return of the affection ; in fact, quite the reverse is the case. 
And neither is the disease ever the result of contagion. Scarlet fever, 
measles, etc., have their favorite period in childhood to an almost univer- 
sal degree, because no one can well escape contact with the infection or 
contagion, rather than because childhood is a cause of the disease. Iso- 
lated communities of adults never exposed to these diseases show but 
little lessened susceptibility to the influence of their contagion when 
brought in contact with it. Individual cases of freedom from their effects 
may be found under all circumstances and at any age, but their bearing 
on the causation of the disease shows almost nothing, while the general 
rule for all individuals has an important effect on the question of age as a 
cause. 

Age seems directly to influence very greatly the form in which the dis- 
ease manifests itself ; in the early period of life the acute articular form is 
by far the most common, while, on the other hand, the chronic form is 



CAUSES OP RHEUMATISM. 25 

very unusual ; in the latter half of life rheumatic fever is, as we have 
seen, a rare occurrence, while the chronic, either succeeding an earlier 
acute attack or attacks, or having originally manifested itself in this man- 
ner, is peculiarly prevalent. Fuller's statistics, collected from his own 
work and the observations of others, show very clearly the period of life 
in which acute rheumatism occurs most frequently ; they do not show the 
number of cases of the two forms of rheumatism occurring in the two 
respective periods of life, but he argues, partly from the general medical 
observation, but chiefly from the nature of the poison or materies morbi 
of the disease, and the manner or cause of the origin of this material, that 
the chronic form of the disease is more common in older subjects than in 
youth. We may accept the statement with very great certainty of its truth, 
that advanced age is more liable to rheumatism, though not in its acute 
form, and also that this fact is directly traceable to changes in the vital- 
ity of the tissues and their functional activity. It is probable, although 
the numerical proof is very difficult of attainment, that there are a greater 
proportion of people advanced in life who suffer from rheumatism in its 
chronic and subacute form, and, perhaps, suffer more or less continuously 
from it, than the whole number who, in youth and early age, are attacked 
with rheumatism in any of its forms. The proof is almost beyond our 
reach, for the vast majority of cases of the lesser grades of the disease, in 
both periods, do not come under observation ; but especially is this the 
case among old people, because it is generally concluded that such pains 
and stiffening of the limbs are but the natural concomitant of age, which it 
cannot be hoped to escape, and for which but little relief is to be obtained. 
That age may exert a strong influence in modifying the form of the dis- 
ease, and that this is directly due to difference of tissues, incidental to the 
period of life, is readily to be accepted ; that, however, it offers a proof of 
the nature of the disease or of the actual presence of a materies morbi, 
and the mode of its production must be a matter of pure speculation 
The latter part of the subject must be discussed later on. 

We must conclude, therefore, that in early life rheumatism in any form 
is a rare affection ; that from puberty to the age of thirty or thirty-five years 
acute rheumatism is a very common disease, from thirty to sixty a much 
less number of persons suffer from acute attacks, but still this form is not 
rare, and that many more suffer from the subacute or chronic form than in 
the preceding period. During the middle period very many die from heart 
disease incident to previous acute attacks. After this period a very much 



20 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

larger number are affected by chronic rheumatism, in a greater or less 
degree, and many fewer from the acute form. Taking the whole number 
of patients, those who have had acute attacks in the earlier period, those 
who have heart disease from this cause compatible with continuous exist- 
ence, as well as those who have escaped chronic cardiac complications, 
and also those who acquire the disease merely in its chronic form, the 
total suffering from rheumatic affections is much greater in the latter part 
of life than at any other period. Past seventy years those who have never 
suffered from rheumatism very rarely acquire the disease, but remain ex- 
empt from its inflictions through the rest of their days. Many, however, 
who have had rheumatism in one or other forms, are still found having 
the chronic malady. In thus summing up the forms of the disease, and the 
ages at which it occurs with greatest frequency, nothing has been said of 
the probability or improbability of the various forms owning and being pro- 
duced by different and unlike causes. These forms of this disease now 
classed together are very unlike each other, and have so few phenomena 
in common, except pain and the place of its occurrence, that many are 
willing to do for them the office, viz., reclassification, already performed for 
so many other maladies, which for these reasons, and these reasons only, 
were previously grouped as rheumatic. This question will be noticed 
under the separate forms of the disease. 

By some observers it is contended that acute attacks develop a tendency 
to the occurrence of the chronic form of the disease, while others view the 
acute paroxysms as an effort of the system to rid itself of a noxious mate- 
rial, and that if the paroxysm is fully developed, the effort is usually suc- 
cessful. It will be easy to recognize under these opposing conclusions 
the bias which the theory of the causation of rheumatism has had in in- 
fluencing the deductions made from observations. It is to be feared the 
upholders of the theory of diathesis have been warped to believe that the 
diathesis once developed — and having expressed itself, as it most usually 
does, according to them, in an acute attack — thereafter there is entailed 
on the person a tendency to the continuation, perhaps in a modified form, 
of the malady and all the dreary evils which the word diathesis implies. 
According to these observers, the greater frequency of rheumatism in ad- 
vanced life, and especially its chronic form, is readily accounted for, and is 
the result of an hereditary or a developed or engrafted diathesis. Other 
observers, who contend for the cause resting on a materies morbi — and 
these, unfortunately for their argument, hold most strongly to its heredi-. 



CAUSES OF RHEUMATISM. 07 

tary nature — point out that the accumulating poison expressing itself in 
an acute paroxysm frees the system thereby from the morbid matter and 
remains less liable to attack — that no rheumatic symptoms present them- 
selves until a reaccumulation takes place in the blood. They hold that 
the paroxysm which is supposed by them to be the means of expelling 
the poison, is little likely in itself to perpetuate a diathesis, but rather to 
counteract it. The freedom from rheumatic symptoms immediately suc- 
ceeding a single attack strongly makes in favor of the purging of the sys- 
tem of a noxious matter and as strongly in opposition to the theory of a 
diathesis. If the diathesis were markedly enough pronounced to produce 
a "well developed attack," "the victim of the disease would inevitably be 
a martyr to rheumatism for the remainder of life." Facts can be accumu- 
lated without end, in the multiplicity of the various phenomena of rheu- 
matism in its many forms, to support the one or the other theory, but so 
long as the cause of the disease remains problematical, the theories must 
remain unsubstantiated. 

Sex. — It is interesting to know whether men or women suffer more 
from rheumatism — the one sex or the other. Very various opinions have 
been expressed with regard to the preponderance of cases of the disease in 
the one sex over the other, and the majority of writers think that men are 
more liable to its attack than women. Among 7,230 cases of rheumatism 
in which the sex of the patient is indicated, 4,293 were men and 2,937 
women. These numbers include all varieties of rheumatism, and have been 
collected from many sources — in fact, are the summation of nearly all 
the statistics which I have been able to find. They are mostly taken from 
hospital records, and merely show the number of cases, which, from their 
gravity, lack of home care, or other causes, sought public treatment, and 
do not indicate the relative proportion which exists in the whole popula- 
tion. There are always, in every community, and especially in the largest 
-cities, more men who seek hospital care than women, and this is found to 
be the case even when in the general population the number of women 
.exceed that of the men. 

There are a number of points to be noted in relation to the statistics of 
sex and the various opinions expressed by authors on the relative liability 
of men and women to rheumatic disease. In those countries, especially the 
rural sections, where the women, by the nature of their occupation, ex- 
pose themselves equally with the men, the proportion of cases, on a 
review of the figures given above, are found to approach an equality of 



28 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

the sexes. Again, in manufacturing cities the same relation is found. A 
comparison of the opinions in relation to the frequency of the disease in 
the two sexes shows that many writers are unconsciously biased in their 
judgment by their views of its causation ; those who hold that rheuma- 
tism is a diathesis, inherited or acquired, and to which every one is liable 
who leads a certain peculiar mode of life, naturally disregard the question 
of sex as in any respect influencing the liability to attacks. Or if the sub- 
ject is alluded to, they explain the preponderance of one sex over the 
other by the habitual mode of life which may favor the development of 
the disease ; some, on the one hand, that men expose themselves more to 
vicissitudes of weather, or werk harder ; others say that the sedentary life 
of women is equally cogent. Those who believe that rheumatism is in 
great part the result of, and is developed by, external agencies, producing, 
of course, peculiar functional derangements, point with telling effect to its 
great frequency in men who are more exposed by habit to such influences, 
thereby at one and the same time finding a cause and showing its effects 
in producing the disease. Finally, those who hold that a peculiar mate- 
ries morbi is the efficient cause of rheumatic affections, express the belief 
that, irrespective of sex, only those, and, of course, all those, who through 
want, irregularities in living, and neglect of health, tend to develop this 
poison in their animal economies, are most liable to the disease ; such ex- 
citing causes as vicissitudes of weather, occupation, etc., of course con- 
tributing their share. 

The conclusion, therefore, to be drawn, is that probably more cases of 
rheumatism occur among men than women ; we cannot disregard the 
showing of statistics of this fact, however we may criticise the liability to 
errors or incompleteness. The statistics do not compel us to believe that 
sex merely in itself directly influences the frequency of the actual occur- 
rence. It is thought that in early life more men are attacked than women 
with acute and subacute rheumatism, especially from the greater fre- 
quency of this form of the disease among the young ; and that after the 
catamenial period the number of those suffering from the manifestations 
of the disease become more nearly equal among the sexes. Statistics are 
neither sufficiently abundant nor accurate to determine these ratios. 

Connection with General Health and other Diseases. — Opinions vary 
very greatly in regard to the influence which the general state of the 
health has in rendering people liable to, or in directly developing 
rheumatic affections. It would seem that, in a general way, taking in 



CAUSES OF RHEUMATISM. 9 ( J 

view the difference in type, the character and circumstances surround- 
ing the patients, the acute and chronic forms of the disease were not 
influenced alike by the state of health of the individual. The periods 
of life at which the two forms respectively are wont to appear with the 
greatest frequency lend probability to the truth of this opinion. Acute 
rheumatism is most common at an age when life is most active and health 
usually the most robust, while the chronic form is found most frequently in 
conjunction with a decline of bodily function. Of course, many exceptions 
to this general statement are met with, and too much weight in the deci- 
sion of the question must not be given to these circumstances, unless we 
are, in the first place, prepared to show that individuals furnishing the 
instances of the disease are, on the one hand, in the cases of acute rheu- 
matism, in the enjoyment of good health previously to or at the time of 
the attack ; and, on the other hand, that the elderly patients are likewise 
enfeebled by age. Age and state of health must be rigidly separated and 
considered apart, and the one must not be held as implying the other. 

So frequent, however, is the coincidence between the occurrence of a 
rheumatic fever or the development of chronic rheumatism and certain 
morbid conditions, of which it is unjust or misleading to speak as disease, 
that I think we cannot escape the conclusion that the state of health does 
have an influence in producing, or, at least, rendering the individual 
liable to rheumatic affections. It may be questioned with great surety 
whether a person in perfect health ever develops rheumatism. In health, 
the young resist cold, exposure, wettings, or dampness — whatever, in 
short, are looked upon by some as causes of rheumatism. Two young 
people who have each spent the evening dancing sleep in damp beds ; 
one may develop rheumatism, while the other escapes ; and the reason — 
at least, one of the reasons for the variation of the result — must be placed 
to the differences in their condition of previous health. In old persons, 
a feebleness of health, even in the absence of any of the chronic forms of 
disease which tend to occur with special frequency as life is prolonged, 
seems to favor in a high degree the occurrence of rheumatism. 

It is especially to be noted that any directly acting source of weakness 
which may be spoken of as accidental in its nature as distinguished from 
the general one just alluded to, tends strongly to favor the occurrence of 
this disease. All such conditions as make a strong drain on the vital 
powers — for example, nursing or suckling of infants, apart from any local 
exposures, losses of blood, etc., are certainly not uncommon coincident 



30 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

circumstances attending its development. Insufficient or improper food 
is spoken of as one cause of its more frequent occurrence among the poor 
than the richer classes of society. 

The not infrequent occurrence of the various types of attacks during 
or shortly subsequent to certain diseases, indicates either a causal connec- 
tion between the two maladies, or else similar or coexisting influences for 
the two diseases respectively. The older authors especially allude to the 
connection between diarrhoea, mucous discharges, and the sudden suppres- 
sion of these morbid discharges as well as normal ones. In more recent 
times — and not a few instances are probably within the experience of any 
one — it has been pointed out that after both dysentery and scarlet fever 
rheumatism occurs with exceptional frequency. This is true in respect to 
these diseases not only as they occur in their epidemic form, but after 
more or less isolated cases. How far atmospheric or epidemic causes 
influence the relation is undetermined, although it is possible to suppose 
that the two are connected. Much more likely is it, however, that the 
precedent disease either develops in the system the cause of the rheuma- 
tism or leaves the body in a condition especially prone to be acted upon 
by other causes or favoring external circumstances. It is probable that 
the so-called epidemics of rheumatism occasionally reported by early wri- 
ters have occurred as a sequence of some prevailing disease, for a true 
epidemic of rheumatism is not at present recognized. 

Rheumatism, usually of an acute type, following scarlet fever, generally 
comes on before desquamation is fully completed, and it would, therefore, 
seem to owe its origin to the changed condition of the skin, by which either 
its function is altered or rendered more sensitive to external influences. In 
dysentery, convalescence is usually nearly completed before the rheumatic 
attack begins, and in this case it has been thought to owe its origin to 
impaired digestive function. Of the actual connection of either of these 
diseases with rheumatism nothing is known positively, and, on the whole, 
their conjunctions occur so rarely that we are provided with but very brief 
data for the study of the question. The puerperal state, as well as the 
complications or accidents which arise out of it, furnishes a not inconsid- 
erable number of cases of rheumatism in one or other of its forms. 
Whether there is some special influence connected directly with the con- 
dition of pregnancy and the results immediately following this condition, 
or whether it is merely that the conjoined accidents, such as already 
alluded to, reduce the powers of the organism, is an unsettled question. 



CAUSES OF RHEUMATISM. 31 

That it is the latter, rather than the former, is probable, from the small 
number of actual rheumatic cases occurring during the puerperal state, 
in comparison with the whole number of deliveries. Chomel regarded 
the sudden suppression of the lochial discharges as the cause of the ap- 
pearance of the rheumatic attack. It is certain that not a few of the 
cases occurring during the puerperal state develop subsequently to the 
natural cessation of this discharge, and, therefore, are unconnected with 
it. While it is a familiar fact that disease is produced by the suppression 
of the menses, yet it is much more probable to suppose in nearly all cases 
that the morbid condition leads to the stoppage rather than the reverse ; 
that, in other words, the suppression is the effect rather than the cause of 
the disease, and that the morbid state, if it is one of true rheumatism, is the 
cause of stoppage rather than a phenomenon developed by the retention in 
the uterus of materials which naturally are voided. Our present knowl- 
edge of puerperal fever and pyeemic joint disease leads us to a just expla- 
nation of the arthritic and other symptoms which unquestionably are of 
frequent occurrence, and has contributed to lessen our estimation of the 
number of instances of rheumatic disease occurring in connection with the 
parturient period in comparison with that formerly held. 

In this connection it is proper to allude to the views held by Dr. Todd of 
the probability of the development of rheumatism from the absorption of the 
unhealthy secretion of the diseased unimpregnated uterus. He makes the 
comparison of these cases to the puerperal form of rheumatism, and also to 
those occurring after gonorrhoea, and, therefore, this view of their origin is 
open to much the same criticism as that just now made. The gonorrheal 
rheumatism is at present separated as a distinct disease, and it is probable, 
if it is at all possible or desirable to erect the uterine cases into a separate 
class, that this form of rheumatism is likewise of a septicemic nature. 

In considering this form, as well as the puerperal form of rheumatism, 
authors who hold variously the diathesic and the blood-poison views, or 
the view of its origin from cold, exposure, etc., become at great variance 
with each other, and not infrequently also with their own theories, in 
explaining the action of these diseases in producing rheumatic symptoms. 
So that it would seem that such diseases, as well as others of quite unlike 
nature, while occasionally followed by rheumatism, bear to its occurrence, 
not a specific relation, but merely one of accident, and are like numerous 
conditions which depress the tone of the organism and render it suscep- 
tible to the development of this illness. 



32 



GOUT, AND ALLIED DISOPwDERb. 



Some of the infectious maladies, either at their inception or subsequent 
to their attacks, are attended with the phenomena which closely resemble 
rheumatism ; of such may be mentioned syphilis and typhoid fever. 

Climate, Country, Race, and Change of Habitation. — Eheumatism reigns 
as a most frequent disease pre-eminently in temperate climates, and we 
may almost speak of it as a disease limited by geographical latitudes. 
This fact is more especially true of acute rheumatism or rheumatic fever, 
for it would seem that the joints and muscles of the old and feeble ache 
and stiffen the world over. So striking is this difference in the geo- 
graphical distribution and occurrence of the two forms of the malady, that 
it has been made use of as one of the arguments for separating the two 
forms into different diseases. 

The older authors all speak of the variableness of the climate as a pro- 
ductive cause, and of this condition as having more influence than either 
extremes of heat or cold ; the more rapid the change the more noticeable 
is the effect. Latitude is not necessarily controlling in its influence ; high 
situations within the temperate zone are liable, according to situation and 
exposure, to more or less unfavorable variability than the lower levels adja- 
cent to them. Chomel states that rheumatism is rare either at the poles 
or the equator, but is common throughout the temperate zone, and in 
countries which are humid and marshy. Fuller shows that among the 
soldiers of the British army admitted into the military hospitals of the 
various colonies, the disease is "not so prevalent in the cold climate of 
Nova Scotia and New Brunswick as at the Cape of Good Hope," and by 
the reports from India, "in its acute form, at least, the disease is very 
rare within the tropics, and as we draw toward the poles the symptoms of 
acute rheumatism are almost unknown." Different portions of the same 
country appear to vary in the number of cases which prevail ; in England 
it is found that in the eastern counties the number of acute cases exceed 
those in the western, owing, it is thought, to their exposure to the damp 
and colder northeast winds. In many parts of the European Continent, 
in fact, parts in which climate and exposure in nowise differ, or are even 
apparently more favoring, the inhabitants are rarely affected with the dis- 
ease or entirely escape. 

It seems apparent, therefore, that other influences connected with the 
situation besides those just alluded to concur in shielding or in inflicting 
the population with the malady. One of these influences to which, not 
only in this disease but in many others, no mention has been made here- 



CAUSES OF RHEUMATISM. 33 

tofore, or, at most, but slight study has been given, is the relative differ- 
ence in soil. We know that, for example, in dysentery, no more potent 
factor exists in determining its endemic prevalence than the character of 
the soil. This rule is, perhaps, more true, or, at least, noticeable in the 
temperate zone, where, except under certain extraordinary circumstances, 
the disease occurs sporadically, rather than generally, as in hotter lati- 
tudes. It would seem that the prevalent diseases are influenced more by 
the deep or subsoil conditions than by the superficial, although many 
modifications may be brought about through changes in the surface-con- 
ditions, due to length of occupation of the soil by an abundant population, 
the drainage, as well as other causes ; and this is more especially the case 
in reference to certain infectious diseases, as dysentery, etc., than for 
rheumatism and other maladies belonging to its class. To illustrate the 
matter, let us take a situation which, from the character or arrangement 
of underlying geological formation, would be favorable from its dryness, 
etc., to lessening the conditions that tend to develop rheumatic disease. 
Such a situation would be made favorable to the increase of the disease 
by having overlying it a surface-covering of impermeable clay ; and this 
would be further increased if, from increase of the inhabitants, their 
drainage and water supply, the clay soil retained a large amount of 
water. At the present time our knowledge of the influence of soils on the 
atmospheric conditions, and, consequently, on its inhabitants, is so lim- 
ited that we are not prepared to speak definitely of such influences ; but 
it is probable mutual relations between the soil and climate and its preva- 
lent disease will be found to exercise a great influence on the health — 
probably much greater than at present supposed. It is believed by many 
observers that the soil exercises as much influence — nay, more, on the 
health of its dwellers than the prevailing winds which blow over its sur- 
face. I know of many places in this country where such influences are to 
be traced in the clearest manner. 

In considering the question of climate and situation as influencing the 
prevalence of rheumatic affection, it is important that we should not omit 
speaking of race peculiarities. It cannot be doubted that some races 
show a greater susceptibility to certain diseases than others, although the 
accurate determination of such a question is one of the greatest difficulty, 
since races of men seem so closely wedded to climate and situation that 
the two are not separable, and we never learn to know them apart. Races 
are usually spoken of as hardy or otherwise, owing to the climate to 



3-i RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

which they are habituated, although some nations of people do undoubt- 
edly possess and maintain certain peculiarities apart from, and in spite of, 
changes of situation, or any other influence which may, in the course of 
time, be brought to bear upon them. If, therefore, some races or nations, 
under changed conditions, evolute and become possessed of other quali- 
ties, while others resist such influences, we can fairly argue that, in re- 
spect to a certain disease, or it may be all diseases, a similar evolution 
may take place, and that nations may thus retain or increase their suscep- 
tibilities to certain noxious influences, or they may lose them, and at the 
same time some diseases may vanish, while others make their appearance. 
In this country, with its mixture of so many races and nations de- 
rived from every source, who permanently dwell here, the study of this 
question can be made under specially favorable circumstances for its solu- 
tion, as the climate differs so radically from that of countries from which 
our new people are derived, and as the individuals become so perma- 
nently incorporated, and remain subject both to new modes of living and 
to the changed climatic influences. Unfortunately, we are defective under 
any existing regulations in obtaining reliable statistics of the prevail- 
ing diseases ; of the deaths only do our reports give us information. 
However, it is in hospitals where such questions can be studied with the 
greatest accuracy, and it is to the public institutions for medical relief 
that our new population naturally resort in greater numbers than those of 
native origin. From a large observation, during many years, of this class 
of patients, the conclusion I have drawn is that our foreign population are 
much more subject to rheumatic disease than those native born ; and, in re- 
spect to the Irish nation, which form the largest part of this class, judging 
both from such statistics as are available and from their own belief in the 
matter, they, as a nation, are more liable to rheumatism, especially in its 
acute form, in their new than in their old home. It must be remem- 
bered, however, that with us, speaking generally, they are, as a class, en- 
gaged in occupations which are supposed to especially favor this disease, 
and, of course, this fact would counterbalance the influence coming from 
mere change of climate, supposing, of course, that such change actually 
has a real material effect in increasing their susceptibility. To these in- 
adequate grounds for a conclusion must be added the changed type of the 
disease and the variable denomination given to the word rheumatism by 
different observers in different countries. 

Seasons, Atmospheric and Barometric Influences.— Seasons of the year 






CAUSES OF KHEUMATISM. 35 

have an equally striking influence in determining the prevalence of rheu- 
matic disease. All statistics show that the common opinion is correct in 
assigning to the summer or warmer portions of the year a fewer number 
of cases than the inclement season. From May to September there oc- 
curs a very great diminution, while during the remaining three-fourths 
of the year it is prevalent. Following the same tendency as in change- 
able climates, the most variable months of the year furnish the largest 
number of cases — the spring months more than winter, and these latter, 
with their steadier cold, more than the autumn. The month of May, 
both in this country and England, during which winter often meets sum- 
mer, is the most unfavorable, and a larger number of acute rheumatic at- 
tacks occur. Variations in the number of rheumatic cases, as influenced 
by the seasons, show great differences from year to year, and from season 
to season we constantly witness favorable or inclement autumns, winters, 
and springs. 

In respect to variability of climate and seasons, I wish to call attention 
to certain atmospheric conditions, of which I have not seen any definite 
mention made. Among the older writers frequent reference is made to 
subtle and unknown atmospheric conditions and influences, of which no 
explanation is given. Later, however, the causes of rheumatic disease are 
mostly placed to the account of changes of temperature, moisture and 
dryness, and no notice is taken of atmospheric causes other than these. 
It has seemed probable to me that these subtle atmospheric influences to 
which the older writers allude have a reality to which we have not given 
full credit. It is true the influences which I mention were unknown in 
their true characters, and were regarded by them as mysterious. Perhaps 
their full appreciation has only become possible in this age of weather 
signal service bureaus, when every morning and evening the heretofore 
subtle condition of the atmosphere is forced upon our attention by the 
barometric record spread before us in the daily paper. That the pressure 
of the atmosphere does influence our bodily condition needs but to be 
stated to carry with it a full belief in its reality, and that, under diseased 
conditions, the rapid variations, as shown on the barometric scale, should 
exercise a stronger influence, is even more evident and rational. Every 
one, if at all observant, or whose attention has once been called to it, has 
often noticed unfavorable changes in patients suffering from typhoid or 
other continued fevers, pneumonia, etc., and in many chronic maladies — 
for example, valvular heart disease — and that a sudden fall in the atmos- 



36 

plieric pressure is likewise capable of accidentally determining tlie time of 
their fatal issue. Among patients who have suffered a long time from rheu- 
matism, no more common observation is current than that changes of 
weather are foreshadowed by an increase of their " rheumatic " pains and 
stiffuess. It is also true that very frequently the rheumatic pains prove to 
be false prophets, and that no rain follows the prediction. 

My own careful and somewhat extensive observations and comparisons 
on the relations between rheumatic pains and changes of the weather have 
led me to the following conclusions. The painful symptoms do not pre- 
dict a rain, but are an indication that the barometric pressure is lessening ; 
and as we know the oncoming of a storm is usually preceded by a falling 
barometer, the pain and the subsequent rain become phenomena closely 
correlated in time, but not as effect and cause. The hygrometric relations 
have little direct connection with the occurrence of pain, and this symptom 
is often developed prior to an increase, either actual or relative, of the 
amount of moisture in the air, so that it is not the dampness which causes 
the pain. It is not a merely low barometer with which this symptom 
corresponds, but it is a rapid change in its indications, either falling or 
rising, which seems to be the efficient cause. A rapid rise is sometimes, 
though less constantly, productive of the rheumatic phenomena. The 
period of the actual storm, during which the barometer is stationary or 
is higher, is usually free from pains, although they may persist coinci- 
dently with a greater dampness of air or other causes. That pain 
should occur from this cause without rain following is as evident as the 
fact that sudden rises or falls of pressure occur unconnected with storms ; 
that a rising barometer is less frequently attended or preceded by pain 
than the falling, is to be accounted for by the fact that depressions are 
usually suddenly developed, while elevations come more gradually and 
promote, even in the healthy organism, which is less affected by these 
variations than the diseased, a more robust and bracing condition. Why 
this result should obtain is unknown with certainty, though many specu- 
lative ideas or glittering generalities could be advanced for its ex- 
planation. 

I have also observed that acute rheumatism, except during the critical 
period, follows, though I think to a less extent, the rule in other fevers, 
and is little influenced by the barometer, especially with reference to the 
pain, while in chronic rheumatism the phenomena are seen with striking 
regularity. 



CAUSES OF KHEUMATISM. 37 

Occupation and Manner of Life. — Irrespective of any consideration of 
the theories of rheumatism, whether a diathesis or a materies morbi, or 
whether its causation be cold, dampness, etc., all of which have influenced 
opinions as to these circumstances, it is unquestionable that certain occu- 
pations and modes of life render individuals prone to rheumatic disease. 

The other conditions we have already considered favor or nullify the 
effects of these two causes, but even the lightest work, the most sheltered 
occupation, and the most careful mode of life are not free from the effects 
of this disease, although all of these circumstances in the highest degree 
lessen the liability to it. 

Severe physical exertion is held by many to directly increase the 
tendency to rheumatism, and if this is performed habitually, under ex- 
posure to the weather, or to sudden changes of temperature, the conditions 
for its development are much favored. Insufficient protection of the 
body, especially after the cessation of labor or exercise, greatly promotes 
the chances of acquiring the disease or at least of developing its acute 
attacks. Cold, applied by immersion in water, or by rain, furnishes 
abundant examples. Rapid changes of the surrounding air, either in its 
amount of warmth or its movement by winds and draughts, specially in- 
crease the liability of those exposed. Clothing rendered damp by rain or in- 
sufficient drying and allowed to remain on the person, especially if affected 
by rapid currents of cool air, and also even by warmth in the sun or in 
rooms artificially heated, is productive of a similar result. Sleeping in 
damp beds and living in damp houses are to be enumerated in the same 
class of productive causes of the disease. If to these are added a manner 
of life, unhealthy from excesses or defective in comforts, insufficiency of 
food or its poor quality, and oftentimes, too, simply the irregularities in 
the hours of eating, sleeping, and working, it would seem almost that 
the only reason for escape from rheumatic disease was a power of resist- 
ance of the organism too strong to succumb to the evil, and even this 
bar is broken down in time and finally such causes produce their usual 
effects. 

In my own experience, the largest number of cases, in which the occu- 
pation at the time of the inception of the symptoms was definitely as- 
certained, furnished by a single class, were of firemen, including both those 
engaged as stokers on ocean-going steamers, where the circumstances are 
particularly exposing, and those working in firing steam boilers on land. 
In this labor the variations from intense heat to cold draughts are prob- 



38 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

ably more frequent and constant than in any other occupation. Next in 
numerical order come the maid-servant, laundress, and maid-of -all-work — 
all three are classed together, as liable to the same kinds of exposure and 
under similar unfavorable circumstances. Neither class, nor both com- 
bined, formed a majority of my cases. 

Temperament and Constitution. — Temperament and constitution are 
generally spoken of by the older writers as exercising an influence in the 
causation or development of rheumatism, but in recent years so much less 
attention has been given to their influence in diseased conditions that 
these subjects now receive little or no discussion. In these days of the 
stethoscope, thermometer, microscope, aesthesiometer, and ophthalmoscope 
no methods of measuring disease and its effects are very much regarded 
which are not effected by exact instruments, subject to record and exact 
comparison. One does not know where to turn to obtain any recent infor- 
mation of such questions as temperament and constitution, except, of 
course, in a few diseases. How much has been lost or gained by their 
passing away from medical discussion, where formerly they held so promi- 
nent a position, the temper of the present age is not fitted to determine. 

Injuries. — Pains, so frequently spoken of as rheumatic, consequent on 
injuries, do undoubtedly exist and are familiar to every one ; but whether 
injuries in themselves, as was formerly the opinion, are productive of 
rheumatism in any of its forms depends largely on the limitations given 
to this disease. 

Sleep.— The conditions of sleep and waking, when we trace the histories 
of rheumatic attacks, are found frequently to influence the receptivity of 
the organism to cold, and to lead thus to the development of the disease. 
We are all familiar with the effects not infrequently resulting from lying 
asleep on the damp grass while the body is overheated and perspiring, or 
of sleeping under an open window. I have met with a number of patients 
who, sleeping by the open window of a railroad car in motion, have been 
attacked with rheumatism. 

It is supposed that during the condition of sleep the organism is less 
capable of resisting the influences which develop the rheumatic condition, 
or at the least is more subject to impressions of cold. Of course this 
development 'after exposure to cold during sleep does not directly prove 
that the organism while in this condition is more susceptible to such influ- 
ences from this cause. It is known that in sleep the condition of the cir- 
culation is altered, but this does not prove an increased susceptibility. It 



CAUSES OF EHEUMATISM. 39 

must be remembered that the fact of sleeping implies a long exposure to 
such influences — longer, at least, than if the person were awake, and unless 
there can be shown a greater liability in sleep than results from an equally 
long exposure during waking, the influence of sleep is not clearly shown. 

Although rheumatism is looked upon at present as occasional and 
sporadic, by the older writers not infrequent mention is made of epi- 
demics of the disease. That favoring combinations of weather, season, and 
climate may vastly increase the number of cases, or that subsequent to 
other prevalent diseases, as already alluded to after dysentery, it may be 
unusually prevalent, seems unquestioned, but in all other respects the rheu- 
matic type of disease is deficient in the characters of an epidemic malady. 

This disease is said to be endemic in some countries and certain 
localities, and in a certain sense this may be true, as already spoken of in 
discussing the influences of soil, weather, and situation, as well perhaps as 
from other conditions, such as occupation and mode of life. But to apply 
the words epidemic and endemic to rheumatism is certainly a misappli- 
cation of terms, and deprives them of the implied meaning, universally 
connected with them, of contagiousness or infectiousness. 

Former Attacks and their Effects. — In respect to the predisposition of 
rheumatic patients to a return of the disease, some misunderstanding of 
the question has arisen among writers from confusing a liability to 
subsequent attacks with the tendency of the disease to relapse, even be- 
fore convalescence is established or shortly afterward. These two phe- 
nomena should be rigidly kept apart for separate consideration, and yet, 
from a careful comparison of many statements of the question, it is evi- 
dent that some opinions have been misconstrued and the one result been 
accepted for the other. It is important also to distinguish between the 
various forms of rheumatism in forming an opinion on this matter. 

Here, as elsewhere in dealing with the debatable question of causa- 
tion, the influence of the theory of the nature of the rheumatic process 
has had its influence in moulding opinion. However, I do not think it 
can be doubted that one attack renders a person peculiarly liable to a 
second or even more, and in this opinion most authors concur. It is un- 
questionably necessary to define accurately, at least to ourselves, whether 
we mean that a chronic form of the affection predisposes a person to acute 
attacks, and also whether we hold that one invasion of rheumatic fever is 
liable to be followed by others, or merely that the chronic form is induced 
by such attacks. To say that chronic rheumatism induces a chronic 



40 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

rheumatism is certainly not asserting very much, for the natural history 
of the disease, as well as our conception of it as implied by the name, 
bring up the picture of a perennial, almost perpetual malady. Whereas, 
to believe that it renders its subjects liable to acute attacks, cannot be 
substantiated and is not warranted by the facts. Eheumatic fever is a 
disease of youth, chronic rheumatism the disease of age. If it can be 
shown that the comparatively rare cases of chronic rheumatism of youth 
were especially liable to be succeeded by acute attacks in subsequent years, 
it would go very far in proving the question and, moreover, also the unity of 
these forms as a pathological process. The question of the liability of one 
attack of rheumatic fever to be followed by subsequent ones, or by a 
chronic trouble, must be settled by statistics. I do not find that any 
statistics exist sufficiently extensive to prove unequivocally such a ques- 
tion. Many writers show from their records of cases a striking frequency 
of such results, but in some instances these calculations are vitiated by 
inaccuracies or by uncertainty of the character of the former disease. 

It must be borne in mind that the essential facts of the case may be 
obscured by several factors. In the first place, a person who has suffered 
an attack of rheumatic fever rather late in life may wear out the suscepti- 
bility to a second by simply advancing in years, while if the attack had 
occurred earlier in life one or more subsequent attacks might have super- 
vened before old age arrived. And then, too, rheumatism, not in itself fre- 
quently fatal, is often complicated with valvular disease of the heart, 
which ends life before the usual susceptibility to the acute disease is worn 
out. This factor likewise must materially reduce the actual number of 
persons living at any one time who have suffered from a second attack, 
although by some observers the cardiac disease is held to increase the 
liability. On the other hand, there is a factor which unquestionably tends 
to diminish the number of second attacks of acute rheumatism, whatever 
may be its influence on the chronic form of the disease, and that is, that 
once a person has suffered from rheumatic fever he naturally is more 
careful in respect to exposure and shuns the conditions, so far as able to 
do so, which, to say the least, favor the development of the disease. Many 
are compelled to seek light work or different occupation owing to the 
occurrence of cardiac disease, and thus may escape second or subsequent 
attacks. 

How far statistics are competent to prove the peculiar liability which 
one attack induces for others, may, I think be questioned, or at least 



CAUSES OF RHEUMATISM. 41 

should be scanned very closely. The record of cases of rheumatic fever 
show that very varying periods of time elapse between the attacks. I 
know of none, and have not been able to find a record where the period 
was less than one year; usually "from three to five, sometimes even ten 
years " elapse. It would naturally be supposed, I think, that if one 
attack was an essential factor in predisposing to another, the paroxysms 
should follow closely upon one another. It is difficult to find a reason 
why an attack of rheumatic fever renders a person " peculiarly liable " to 
another ten years subsequently. Todd believes that the full establishment 
of the diathesis renders the patient " very liable to similar attacks," and 
Fuller says that "a paroxysm is evidently but an effort of the constitution, 
and generally for the time an effectual effort, to get rid of the poison," and 
seems to imply also that if the effort is thorough enough no more attacks 
would occur, provided sufficient care were exercised to avoid exposure 
and proper medical treatment instituted to restore the system to com- 
plete health. 

This question is certainly a difficult one to decide, as are so many 
others of a similar nature, where the proof is in so large a degree purely 
numerical, without our first possessing a pretty clear — certainly very 
much clearer than we at present have — notion of the essential cause of the 
disease. 

'Drugs. — The discussion of the effects of drugs, cold, and general func- 
tions of the organism and the influence they have in producing or favoring 
the development of the disease, if they have such power in any material de- 
gree, we shall leave until the pathology of the disease has been considered. 



CHAPTEE IT. 

PATHOLOGY. 

The Various Theories : The Local or Inflammatory ; the Vascular ; the Nervous, 
comprising the Electric, the Spinal, and the Vaso-motor ; the Specific Poison, or 
Lactic Acid Theory ; the Physiological and Chemical Origin and Nature of the 
Lactic Acids ; the Defects of this Theory ; the Infection Theory. 

The Various Theories. 

The nature of the proximate cause of rheumatism remains to-day 
among the most unsettled questions of pathology, and little has been 
added to our actual knowledge in relation to it since the earliest time, 
although so much accuracy in its clinical aspects has been acquired mean- 
time. 

We may pass by the primaeval theory of its origin from " the defluxion 
of an acrid humor, generated in the brain, into the various parts of the 
body," and at the same time be careful not to drop into this same humoral 
error presented in a new and more exact chemical form. 

"We must, however, consider carefully other theories which have 
been studiously wrought out and have received the sanction of eminent 
physiologists, pathologists and clinical workers. Of these theories four 
demand very special notice. First, what may be called the local theory ; 
second, the specific poison ; third, the vascular theory ; and fourth, the 
vaso-motor or nervous. The last theory is closely allied to and its views 
intermingle with the previous one, and also with the electric view of the 
origin of the disease which has been held by some observers. Eecently 
an infectious nature has been proposed for all the rheumatic phenomena, 
and since the germ theory of disease has become so popular it has 
acquired quite a number of adherents and advocates. 

These views cannot be discussed in chronological order, and the order 
in which they are mentioned here is not intended strictly to conform to 
this method ; in fact, these various theories have in point of time com* 



PATHOLOGY. 43 

mingled and are yet held contemporaneously; at one period or other, each 
view has had its successful advocate and has for the time become perva- 
sive. At present, at least among English authors, and to a very great 
extent in other countries, the specific poison theory holds its sway. 

The Local or Inflammatory Theory. — Sydenham was the first one to 
definitely state his belief of the proximate cause of rheumatism and to 
conform his treatment in accordance with his views of its nature : his 
pathological notion was that the disease was an inflammation of the joints; 
that it was a local affection attended with various general symptoms 
which owed their origin to the joint disease. In this view he was followed 
by Cullen, and numerous others, and Cullen further expresses the opinion 
that " the cause of acute rheumatism appears to be exactly analogous to 
that of the inflammations depending on an increased afflux of blood to a 
part while it is exposed to the action of cold," and he denies the existence 
of a " peculiar acrimony " of the blood as a supposition without reason and 
one founded on the humoral pathology of the ancients. 

Scudamore, while holding that rheumatism belonged to the class of 
phlegmasia^ speaks more particularly than previous writers of its specific 
characters and of its constitutional relations. He says that " rheumatism 
in its true primary character is not so distinctly a constitutional disease 
as gout;" that "rheumatism is a disease external to the system, which itself 
becomes affected in a secondary manner by sympathy ; but, in turn, it 
reflects back its influence upon the external parts." " Although it oc- 
casionally happens in point of time that pyrexia precedes the develop- 
ment of the local rheumatic inflammation, may we not consider that the 
constitution has taken such early alarm from a ready sympathy with the 
textures upon which the offending agent, cold, has certainly made its im- 
pression, notwithstanding the characteristic symptoms do not become all at 
once developed ? Yet the interval between the occurrence of the consti- 
tutional fever and the local signs of inflammation is never long ; and the 
general fever, inasmuch as it is truly rheumatic, keeps pace entirely with 
the local disease." "It may be stated that the predisposition to rheuma- 
tism consists in a deficiency of healthy tone in the textures, connected 
with joints and muscles, and in nerves, so as to be affected in this peculiar 
manner by the influence of variable temperature. If we lose sight of the 
humoral term 'rheumatism,' we shall come to the simple fact that in a 
condition of susceptibility cold, or sudden reduction of temperature, 
makes a particular impression on the vessels and nerves near the surface, 



44 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

and produces a painful affection of certain textures, which is attended 
mth more or less of inflammation, the phenomena of which are so far of 
a peculiar nature that we may either consider the disease specific, 
inasmuch as the symptoms differ in their constituent characters from those 
produced by other inflammations, or we may view the effect in the light 
of common inflammation, modified on the one hand by the nature of the 
exciting cause-the external one, cold-and, on the other hand, by the in- 
fluenced the particular species of textures which become affected." 

This view of Scudamore must be rejected, as not grasping in full 
measure the scope of the disease. At the time it was promulgated his 
theory was a great advance on previously held ideas of the pathology of 
the disease, and many of the physiological and pathological notions in- 
cluded in the abstract here given, as well as those found in other parts of 
his work, were of a nature that have only been formulated quite recently 
by the light of many newly discovered anatomical and physiological facts. 
The essential inflammatory nature of the malady is rendered by Scuda- 
more too prominent, and while he admits its general characters, the 
ascription of these to the effects of sympathy is all too vague to corre- 
spond to many of the prominent phenomena of the attacks. The denial 
of any peculiar- alteration of the blood- although such alteration may not 
be regarded as the proximate cause of the disease-is still less in corre- 
spondence with known pathological facts. 

We may, therefore, put to one side the view of its local or purely in- 

flammatory origin and proceed to the discussion of the various other 

theories of its causation. In order to arrive at any common ground, for 

this studv it is necessary to start with some initial symptom or occurrence 

which, by its frequent or almost constant presence, can be looked upon as 

something either forming a part of the disease or as quite essential to its 

production. This phenomenon we find in the "chill." By this is not 

implied that a rigor is universally an initiatory symptom of the malady, 

but that the person affected suffers, through the application of external 

agencies, an abstraction of heat, either general or local. This abstraction 

of heat is so nearly a universally exciting cause, that on it nearly all are 

able to meet as a common field for discussion ; to some of the theories i 

is an essential feature, but to others it would seem merely incidental, yet 

the advocates of all the various views acknowledge its occurrence and 

render its influence a prominent factor in its causation. 

The older theories of rheumatism attempt no explanation of the 



PATHOLOGY. 45 

manner in which the chill develops the phenomena of the disease, ex- 
cept that in the inflammatory theory the bare statement is made that the 
action of cold, or of cold and moisture, produces the inflammation, and 
that this inflammation is modified by the nature of its cause or by the tex- 
ture of the tissues which are involved. Later writers have added nothing 
to our knowledge of the essential nature of chill which is at all adequate 
to the explanation of the phenomena which result from it. 

The Vascular Theory. — Another theory, which has at times received 
considerable support, and especially so when the action or participation 
of the capillary system of vessels in all inflammatory diseases came to be 
recognized and insisted on, was that the train of symptoms recognized as 
rheumatic were set in motion by the local or general abstraction of heat, 
producing a contraction of the superficial vessels. This contraction was 
succeeded by a marked dilatation of their calibre, acting as a rebound, 
and a consequent afflux of blood to the parts most strongly impressed by 
the action of the chill. In cases where rheumatic inflammation succeeded 
to these phenomena, the original impression of the chill was supposed to 
have been sufficiently strong to paralyze the elasticity of the capillary 
wall. The dilatation, by reason of this, was maintained long enough to 
result in an inflammation. The localization of the disease in certain joints 
in preference to others was supposed to ensue either from their greater 
exposure to the agency or from an original inherent weakness, a predispo- 
sition peculiar to the part or one induced by functional activity at the 
time of or immediately preceding the onset of the attack. 

This theory is defective in many points. In the first place, it attrib- 
uted a power to the blood-vessels which is no longer conceded to them. 
The regulation of the blood supply to a part and the phenomena of chill 
in connection with the vascularity of an organ are the result of nerve 
action, and do not result from the state of the capillary walls. Their dis- 
cussion will follow later. The capillaries are non-muscular tubes and do 
not possess the power of self-action in respect to contractility and the con- 
sequent afflux of blood. A paralysis of the capillaries, therefore, cannot be 
brought in question ; it can only be an overdistention, and if any such 
effects are to be attributed to cold or chill, they must be earned back to 
vessels which are possessed of muscular walls. But according to the terms 
of the theory the effect of the chill was a purely superficial one, involving 
the superficial network of vessels. 

Further, this theory leaves out of account many of the associated 



46 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

phenomena of the rheumatic attack, while, if its physiological teachings 
were acceptable, it would harmonize with the inflammatory and local 
notions of the disease ; still, it must be held to be inadequate for the ex- 
planation of the visceral complications as well as the marked blood altera- 
tions exhibited during and subsequent to its action. This theory in no 
way differentiates this peculiar inflammation from others, except that its 
cause is not due to mechanical action, and it does not account for the 
sudden cessation and oftentimes sudden return of the inflammatory symp- 
toms in an articulation, without there having been in the meantime a re- 
application of the same cause. 

For this theory, in the terms which it has been stated, very little can 
be said in support at the present day, and little of it which has not been 
made more definite in its application under the theory next to be consid- 
ered. The purely local part of it belongs to the old inflammatory notion, 
and the participation of the capillaries in producing the effects has, so far 
as they act, been explained in accord with known physiological laws, by 
the mechanism of the vaso-motor or trophic nerves. 

The Nervous Theory. — As the older notions of rheumatism in the course 
of time were deemed inadequate to the explanation of its occurrence, when 
the knowledge of physiological and pathological laws was advanced by 
numerous anatomical discoveries, and even before we had arrived at a full 
comprehension of these facts, another theory was promulgated for the de- 
velopment of the attack. This new theory, as at first propounded, hinted 
at rather than directly expressed the view that the whole train of 
symptoms was the effect of nervous action. 

The Electric Theory. — The earliest of the nervous theories of the cau- 
sation of the disease had to do with the effects of electricity on the system. 
At that time it was generally spoken of as the constitution of the atmos- 
phere, and by sudden changes in this rheumatism, as well as other diseases, 
was produced. Of the many imponderable agents capable of producing 
diseased action and contained in the air, electricity was the chief, the most 
subtle, and the one on which the rheumatic predisposition depended. 
Nervous action was at that time supposed to depend on electric force, if it 
was not itself actually electricity. It was observed that at times when 
rheumatism or rheumatic symptoms were most frequent the electric 
machines furnished but little evidence of electricity, and it was therefore 
concluded that the rheumatic phenomena were dependent on a deficiency 
of electricity in the air. 



PATHOLOGY. 47 

Such a theory found abundant support in days when the knowledge of 
this agent or force was but very imperfectly known. It was shown that 
this supposed electric deficiency corresponded to the times of year, and 
even of the day, when rheumatic diseases were most prevalent and most 
easily developed from exposure. The fallacy of this view was soon made 
evident from the fact that although the machine did not produce electric 
manifestations, yet there was no actual deficiency of this agent in the air ; 
on the contrary, it was not infrequently the case that while but little elec- 
tricity was manifested from artificial excitation, a superabundance of 
the agent existed in the atmosphere, and the very conditions which 
hindered its artificial display, viz., moisture, etc., and conducted the agent 
away as fast as produced, favored an electric accumulation in the air. 
Various modifications of the electric theory found believers, and when the 
dependence of rheumatism on the want of this agent in the atmosphere 
was shown to be untrue, the occurrence of the disease was referred to its 
altered intensity under the influence of moist or dry atmospheric con- 
ditions. 

And again, some thought that a disturbed equilibrium between the 
atmospheric and the organic electricity manifested itself in rheumatic 
phenomena ; others considered that the disease was produced in those 
parts of the body by the interchange of the positive or negative electricity 
of the air with opposite kinds of electricity of the organism ; while others 
again thought that the organism was overloaded with electricity and that 
this condition called forth the pain and other rheumatic symptoms. 
" According to my belief the quantitative potent electricity of the air, 
which passes into the organism, especially through the respiration, and 
the thermo-electricity generated in the organism itself through changes of 
temperature, excite the capillaries, and these occasion an abnormal forma- 
tive action ; electricity brings a vital principle, stirs up everywhere activity 
and life ; but when its incitation oversteps the capacity of the incited 
parts, it occasions an excessive or diseased vitality and decomposition." ' 

The Spinal Theory. — Another phase of the nervous theory of rheu- 
matic affections was introduced by Dr. J. K. Mitchell, of Philadelphia, in 
1831. 3 Briefly stated, his view was that "rheumatism might have an 
origination in the medulla spinalis, and depend on an irritation of that 

1 Eisenmann: Die Krankheits-Familie Rheuma. 1st Band, S. 25, 26. 1841. 

2 American Journal Medical Science, Vol. VIII., 1831 : On a New Practice in 
Acute and Chronic Rheumatism. 



48 

important organ." Dr. Mitchell was led to this opinion from the results 
of treatment of the symptoms of acute rheumatism occurring in patients 
suffering from spinal curvature. His treatment for these cases was de- 
pletion, applied not by venesection or to the affected joints, as in vogue 
in his time, but to the part of the spine involved in the disease, " with the 
effect of procuring a prompt solution of the disease." In cases of both 
acute and chronic rheumatism, coming without any evident spinal involve- 
ment, he found that the "local depletion applied to the spinal region bene- 
fited the disease, which lay at the peripheral extremities of the nerves," 
and "that local blood-letting is most potent when applied to that part of 
the spine which supplies with nerves the parts in a state of active inflam- 
mation." Dr. Mitchell did not further express his belief on the univer- 
sality of this condition as productive of rheumatism ; neither did he point 
out the connection between or modus operandi of the so common pre- 
cedent condition or cause of the disease, viz., cold or dampness, in setting 
up the " irritation of the nervous masses," which in his opinion led to the 
articular symptoms. Whether, in other words, he thought that the in- 
itial chilling acted directly or even generally on the spinal cord, or whether 
the altered temperature communicated itself through the usual nerve- 
channels from the surface to the centres. 

His exceedingly clever and original views on the subject of the causa- 
tion of rheumatism shine out as a brilliant spot to any one reviewing the 
history of this disease, and distinguish his work as a piece of scientific in- 
vestigation of this subject which has been rarely, if at all equalled in the 
centuries which rheumatism has afflicted the human race. No one read- 
ing the records of his cases can fail to feel a confidence in his observations 
or to perceive the true spirit of investigation which he brought to bear on 
the problem before him. And while this view has found but little con- 
currence in professional opinion as an explanation of the cause of rheu- 
matic diseases, I think that more attention should be bestowed on it now, a 
half century after its publication. It will afford a most rational pathology 
for a number of cases of acute, and perhaps even greater number of the 
chronic form of this disease. Many cases also of those exhibiting symp- 
toms in connection with the main nerve-trunks, as in sciatica, not improb- 
ably will be found to have the condition, supposed by Dr. Mitchell, as 
their true pathological change. 

Rheumatism has been shown to have been, according to the earlier 
views of its nature, a medley of morbid conditions. A different nature 



PATHOLOGY. 49 

has been shown between gout and rheumatism, formerly confounded with 
each other, although both belong to the arthritic family. Gonorrheal 
rheumatism, pyemic joint affections, and those occurring in the puerperal 
state are now well recognized as due to separate causes. Arthritis de- 
formans, or rheumatoid arthritis, as well as certain joint diseases due to 
chronic spinal cord changes, have also been differentiated from the main 
bulk of what remains still to be classed a& rheumatism. Is it at all im- 
probable that in the course of time we shall come to recognize a rheumatic 
joint-affection dependent on acute changes in the spinal cord or other 
central nerve-mass, which at present is classed as an acute or chronic rheu- 
matism ? This is what Dr. Mitchell indicated a half century ago, and a 
perusal of his cases and the effects of his treatment render the supposi- 
tion quite, nay, more probable than many of the theories which have 
found acceptance since that time. His observations are the very founda- 
tion of all our present knowledge of the concurrence of spinal, or in fact 
cerebral affections with various kinds of arthritic inflammation, and there 
is undoubtedly an element of truth in them, at least for a certain number 
of rheumatic cases, if the test of treatment, which we have applied as did 
Mitchell, is to be trusted. 

Dr. J. K. Mitchell published a second paper in the American Journal 
of the Medical Sciences, 1833, p. 360, on the connection of spinal disease 
with rheumatic phenomena of the joints, and a quotation from an article 
in the same journal for April, 1875, by his son, Dr. S. Weir Mitchell, will 
show the relation which this early work has to the modern researches on 
the same subject. The latter article is on " Spinal Arthropathies," and 
calls attention to "the history of spinal and neural arthropathies, a subject 
which owes its best study to American and French students." "The his- 
tory of this subject is somewhat interesting, and the more so, because to 
an American physician belongs the long-forgotten credit of the first dis- 
covery that ' an obvious spinal cause may produce a rheumatism charac- 
terized by heat, pain, redness, and tumefaction.' The quotation is taken 
from the second paper on rheumatism by the late Dr. John K. Mitchell. 
In his first essay he described cases of Pott's disease, in which, below the 
diseased region, there were acute inflammations of the joints, which 
proved amenable to treatment directed to the point of spinal lesion. M. 
Charcot, in acknowledging the first mention of these facts, adds, cor- 
rectly, that this cause of arthropathies is rare, and, apparently ignorant of 
Dr. Mitchell's second paper, says that traumatic lesions of the cord are 



50 RHEUMATISM, GOUT, AND ALLIED DISOEDEES. 

more often the parent of joint disorders, and refers to Gull for in- 
stances of spinal commotion as competent to occasion a like result. Until, 
in my work on injuries to nerves, I recalled attention to the true author of 
this clinical discovery, Gull has usually had credit for being fhe first orig- 
inal observer of these interesting facts, while actually the credit is due to 
the American author." " Finally, in 1864, 1 described, in conjunction with 
Drs. Morehouse and Keen, the joint diseases caused by injuries to nerve- 
trunks, and again and again since I have illustrated anew this clinical 
sequence, by numerous reports of cases of manifold forms of nerve in- 
jury." 

Unfortunately, this theory, first promulgated by Dr. Mitchell the elder, 
did not attempt to show the relation between the exposure or other excit- 
ing conditions and the development of the irritation of the nervous masses 
it merely formulated the relationship between the spinal irritation and the 
arthritic or other rheumatic phenomena. Had this been done the work 
would have anticipated by ten years or more the theories promulgated by 
Froriep and Canstatt. Their observations, dating about 1840-5, have only 
become of value as an explanation of the rheumatic phenomena by the 
light of our modern, later-discovered knowledge of nervous action. 

The Vaso-Motor Theory. — The later developments of the nervous 
theory, thus commenced fifty years ago by Mitchell, and continued by 
Froriep and Canstatt ten years later, as well as more recently by others, 
have been characterized by the attempt to explain the pathology of the dis- 
ease in more or less strict accordance with the doctrines of physiological 
pathology. But while the latest developments of this theory insist most 
strongly on the actions of the nerve-fibres, as influenced by external 
causes in instituting the initial steps in diseases, it goes farther in tracing 
their results. According to the older statements, of what has been termed 
the nervous theory, the articular affection was described as the result of 
disturbed innervation, and the general symptoms were regarded by some 
to be dependent on the local affection, and by others as a mixed result, 
partly due to the local disease and partly expressive of the same nervous 
disturbance affecting the system generally. It was supposed — and this 
must be done in order to harmonize the theory with our present ideas — 
that the cold acted directly on the nervous supply to the joints, or that 
this impression was conveyed to the nerve-centres so that, as the result 
either of central or peripheral nervous action, articular inflammatory dis- 
turbances were excited. 



PATHOLOGY. 51 

This theory, which originated at a time when nervous action was be- 
ginning to be observed with increasing attention, seemed to supply the 
wants in the scientific mind by which to account for the erratic character 
of the rheumatic symptoms. It was also a protest against the universal 
tendency of the older phlegmasic pathology, which had so long been dom- 
inant. 

This theory in its bare and simple form has failed to receive any very 
general assent, principally from a lack of proof of the ways and means of 
action of the nerve-fibres, viz., the so-called trophic nerves, in producing 
their effects when subjected to irritations of the character supposed to be 
brought into play. 

The Specific Poison, or Lactic Acid Theory. — The theory of the causa- 
tion of rheumatism which yet remains to be considered is the lactic acid 
theory. The suggestion that this acid was the peccant matter giving rise 
to rheumatism was first made by Prout, and since his time has been taken 
up by others. 

The subject is referred to by Dr. Prout in his considerations on the 
pathology of saccharine assimilation and secretion in the following man- 
ner. In speaking of the development of lactic acid during the secondary 
assimilating processes, he states that the various acids and other unnatural 
matters developed in the stomach and digestive tract appear to be ab- 
sorbed into the system, "where they probably tend to act as exciting 
causes of derangements in the secondary assimilating processes (nutrition). 
The symptoms resulting from such combined derangements, like all symp- 
toms connected with derangements of the assimilating organs, have more 
or less of a periodic character, and show themselves in occasional attacks 
of bilious congestion, gout, lithic acid, gravel, catarrhal affections, ague, 
rheumatism, etc., according as exposure to cold, malarious influences, etc., 
co-operate with the original predispositions and determine their nature." 

After speaking of the character of bilious attacks in their relation to 
this condition, he continues: "In those who suffer from indigestion, 
whether from excess or from disease, the acid and unassimilated matters 
appear to accumulate in the system. Such attacks in the strong and 
healthy are usually displayed in the form of simple feverish excitement, 
and generally sickness and diarrhoea, but in the delicate, and in those pre- 
disposed to other diseases, the weak part, wherever it may be, is usually 
involved in the affection, and suffers in a greater or less degree. Of all 
other parts of the system, the mucous membranes seem to be most liable 



52 EHEUMATISM, GOUT, AND ALLIED DISOEDEES. 

on such occasions to go wrong ; and of all exciting causes, cold is perhaps 
the most common. Thus every one must have observed that when the 
system is so charged, he is liable, on the slightest exposure, to get cold ; 
others in such a state of the system frcm a similar exposure get 
an attack of rheumatism ; others gout or erysipelas ; ... and in all 
such instances the affection is of a mixed nature, and cannot be advan- 
tageously treated without reference to the original derangement of the 
assimilating processes ; and sometimes when this is removed, all the 
other symptoms disappear. . . . Thus bilious individuals are very 
liable, on comparatively slight exposure to cold or to malarious influences, 
to get an attack of acute rheumatism or of ague. ... The condition 
of the system above described preceding what is called a bilious attack, 
being so obviously calculated to predispose the constitution to take on 
further diseased action, we are neither surprised to find that in such a 
state of the system the secondary assimilating processes going on in all 
parts of the economy become more than usually deranged from slight 
exciting causes, nor that those organs should superficially suffer which 
happen from any particular cause to be predisposed. The inferences, 
however, we wish to draw from these obvious facts are, that the severe 
derangements of the secondary assimilating processes going on all over 
the system are nearly allied to certain forms of fever ; while the local and 
specific derangements are identical with certain specific inflammations. 

« Of what fever and inflammation in general consist we do not venture 
to offer an opinion ; but as no one will deny that certain forms of fever 
and inflammation are always accompanied by derangements of the assimilat- 
ing processes, both primary and secondary, and that such forms of fever 
and inflammation are not only preceded by long-continued derangements 
of the primary digestive processes, but frequently have their origin in 
such primary derangements, we may perhaps be allowed to assume with- 
out opposition that some diseases to which we apply the terms fever and in- 
flammation, are practically speaking at least, what we have above inferred 
them to be, viz., only severer derangements of the secondary assimilating 
processes, modified by the peculiar nature of the organs or textures in 
which such derangements exist— inferences that will enable us to explain 
the principles on which derangements of the primary assimilating processes 
predispose to the peculiar derangements of the secondary processes now 
under consideration ; and which we consider to be nearly connected, if 
not identical, with those forms of fever and inflammation usually denomi- 



PATHOLOGY. 53 

nated intermittent fevers, rheumatism, and neuralgia ; . . . and, 
moreover, that these derangements of the assimilating organs are 
usually accompanied by the presence of great acidity of all parts of the 
system. Thus in . . . rheumatism, during the sweating stages of the 
paroxysms, immense quantities of acid (chiefly of lactic acid) are thrown 
off by the skin, and sometimes by the kidneys. In all these cases the 
saliva is commonly acid." 

" In rheumatism, the same derangements, to a less extent, appear to 
exist in the primary assimilating organs ; but, in this case, the secondary 
assimilating processes, by which the gelatinous portion of the muscular 
system and its appendages are produced and maintained, maybe supposed 
to be more especially implicated ; and the loss of power and the great de- 
gree of pain usually present in rheumatism may be referred to the dis- 
order of the numerous nerves of motion and of sense, which, as well as 
the fibrous portion of the muscles, are likewise necessarily affected by the 
derangements. Moreover, on these' suppositions we may explain the 
formation of large quantities of lactic acid usually present in rheumatic 
affections, as well as the swelling, etc. ; for as all the organs are more or 
less involved, and their functions paralyzed, not only imperfect assimi- 
lation takes place in the part affected, but the apparatus destined to re- 
move matters which are unfitted, or no longer useful, from the scene of 
operation, likewise cease to act ; and hence such unfitted and useless 
matters accumulate, and cause swelling in the part affected. In simple 
neuralgic affections, nearly the same explanation may be given. De- 
rangements of the primary assimilating processes, analogous to, or iden- 
tical with, those existing in ague and rheumatism, are always present in 
a greater or less degree in these affections ; while the derangements go- 
ing on in those secondary assimilating processes, by which the nervous 
substance and its immediate appendages are produced and maintained, 
may be supposed to be the immediate cause of the pain and other distress- 
ing symptoms of the disease." ' 

On this subject "Williams speaks in the following manner : " The per- 
spiratory secretion contains lactic acid and lactates of soda and ammonia, 

1 " The reader is distinctly required to bear in mind that rheumatic neuralgia only 
is here alluded to. Neuralgic affections, arising from mechanical or other injuries of 
the nerves, are referable to another class of affections ; but, even in such instances, 
the formation and presence of unnatural matters of another sort may contribute to 
the patient's sufferings." 



r 



54 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

which probably proceed from the transformation or decay of the textures, 
particularly the muscular, which the recent researches of Liebig (1847) 
have shown to contain a preponderance of this acid. Hence these pro- 
ducts abound during great muscular exertion ; and when perspiration is 
checked by external cold they may be retained in the blood, causing 
rheumatism, urinary disorders, or various cutaneous diseases. 

" Rheumatism is especially liable to occur as an effect of cold, when the 
body is fatigued with much muscular exertion ; and I have frequently ob- 
served that the rheumatism chiefly affects the limbs which have been most 
exercised. Where the skin fails to excrete, an increased task is thrown 
on the kidneys, . . . and if these organs fail in the task, the lactic 
acid accumulates in the blood, and, probably acting as a ferment, causes 
the formation of more, and of the kindred products, lithic acid and its 
compounds and products ; these, in inflammatory subjects, excite rheu- 
matic fever ; in cachectic persons, miliary fever, erysipelas, or pemphigus ; 
and in more torpid frames, various local rheumatic or gouty affections. 
All these cases are frequently remarkable for the acid character of the 
cutaneous and renal excretions, and in a few instances the blood has been 
found to possess acid qualities, or to be deficient in its usual alkaline 
reaction. . . . The remedy for rheumatism and other diseases arising 
from defective excretion, therefore, should not be merely antiphlogistic, 
but also of a kind calculated to eliminate the morbid matter from the blood." 
It is probable Dr. Todd has done more to advance this theory and to 
confirm its belief, at least in England and this country, than any one. It 
is he who so strongly insists on the diathesis as the basis of the rheumatic 
state. He says : " The constitution is liable to become modified under the 
influence of cold, imperfect nutrition or defective assimilation, so as to 
give rise to what maybe called the rheumatic diathes is. " After calling 
attention to its resemblance to other diseases confessedly " due to the in- 
troduction of a morbid material into the blood," and insisting that "rheu- 
matic fever " — the term by which he prefers to designate the paroxysms of 
the disease — is not symptomatic of a local inflammation affecting one or 
more joints, but is, as Dr. Graves affirms, a disease which may exist with- 
out the articular affection, he comes to inquire into the nature of the 
morbid matter, which he thinks we may infer to be the cause of the rheu- 
matic diathesis, as well as the rheumatic fever. 

"This," he says, " is even a more difficult inquiry than that regarding 
the matter of gout. In the latter disease, we had some guide in the 



PATHOLOGY. 55 

actual excretion of a peculiar substance, lithate of soda, from the diseased 
parts. The remarkable resemblance, however, between the two diseases, 
may justify our concluding that a certain similarity may exist between 
the morbid matter of each." "The two most remarkable excretions in 
the rheumatic diathesis, or fever, are the urine and the sweat. Both of 
these are distinguished by the presence of an unusual quantity of free 
acid. The urine contains a large proportion of lithic acid." "The 
lithic acid diathesis, however, is by no means so strongly marked in the 
rheumatic as in the gouty state. " " Lithate of soda is never formed in the 
rheumatic paroxysm, nor in the diathesis." " If with these considerations 
we take into account the most frequent causes of the rheumatic diathesis 
and paroxysm, we shall obtain a further clue to the determination of the 
problem we have proposed. These causes must be admitted to be im- 
perfect assimilation and vicissitudes of temperature. . . . Hard work, 
exposure to cold and wet, bad food, are strongly contrasted as causes of 
the rheumatic diathesis, with the ease, comfort, and excess which give rise 
to the analogous one of gout. If, now, we remember that the skin is the 
great emunctory of lactic acid, and that bad food, or too little food, may 
give rise to its undue development as well as too much food, it is no wonder 
that, as lactic acid is imperfectly excreted through its natural channel, in 
consequence of cold in checking perspirations, and is too freely developed 
in the alimentary canal, it should accumulate in the blood and become 
eliminated at every point. Moreover, the long continuance of the causes 
which produce the defective cutaneous secretion and the deranged 
gastric one will give rise to the undue development of the lactic acid in 
the secondary destructive assimilating processes, thus infecting the 
blood from every source and tending to perpetuate the diathesis." 

It is not, I trust, without great interest to review, in their own words, 
the teachings of these great men who have mainly promoted this. theory 
of the pathology of rheumatic affections— the view which to-day probably 
commands more believers than any other. It is especially necessary to 
remember the state of knowledge on animal chemistry at the time this 
theory was originated. Prout was among the early students and ob- 
servers of the animal secretions, and in his first book on urinary diseases, 
written about 1820, nothing is said in respect to the relations of rheuma- 
tism. It is in his second work, written twenty years later, that his views 
are fully developed and expressed, and it is from this volume that the 
quotations given above are taken. 



56 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

It must be remembered, in judging of this theory and the credibility of 
the opinion of those who first promulgated it, that at the time of its in- 
ception the prevalent chemical opinions of the composition of the blood 
and the urinary products were wholly different from those held since and 
at present known for facts. Prout and the chemists of his time believed 
that the blood contained among the other salts a notable amount of lactic 
acid combined with soda. The urine likewise was held to contain between 
seventeen and eighteen parts in a thousand of lactic acid and its compounds. 

This opinion, of the presence of lactic acid as the peccant matter in 
rheumatic affection, was perhaps justifiable, or at least not unreasonable or 
absurd so long as the former chemical nature of the animal economy was 
held to be true. The opinion, however, continued to be maintained long 
after Lehmann and others had discarded it and shown it to be erroneous, 
from the fact that both the blood and urine were partly composed of 
lactic acid and its salts. 

Dr. Prout seems to have honestly held the view that lactic acid was re- 
tained in the system by the action of the exciting cause of the disease, 
viz., cold, or perhaps was generated in increased quantities through the 
derangements which this agent wrought on the secondary assimilating 
processes. But when advanced chemical researches show that this acid is 
not a normal constituent of the economy, this theory must fall at once, 
unless it can be supplemented with pretty distinct proof that under the 
abnormal conditions lactic acid is developed. It, therefore, does not seem 
that Todd and his followers were justified in maintaining this view, since 
neither they, as clinical observers, nor the physiological chemists of that 
time offered such evidence as seems to be demanded by the circumstances 
of the problem. 

Physiological and Chemical Origin and Nature of the Lactic Acids. — The 
origin of the lactic acid, the materies morbi supposed to be the cause of 
rheumatic affections, must be divided for consideration under two heads. 
The earlier notion in respect to the place of origin of the lactic acid was 
that it came from imperfect assimilation of certain articles of food, or from 
altered functions of digestion, and that both of these changes resulted 
from the effects of cold, damp, etc. This view was held to a certain ex- 
tent by Prout, almost entirely by Todd, and Fuller even excludes the 
effects of changes of temperature, etc., in promoting the defective assimi- 
lation which he believes to be the cause of the development of this 
diathesis. 



PATHOLOGY. 57 

The other branch of the lactic acid theory is of late origin, and its 
complete statement has only become possible since modern physiology has 
pointed out the minute details of muscular and articular functions and 
their organic chemistry, This view of the lactic acid theory has been 
pretty fully stated, in fact developed, by Senator, and the main features of 
it are that the acid is developed in the muscles, as the result of their ac- 
tivity, and the effect of the chill is to cause a retention of this as well as 
other effete products, which by accumulation in the system produce rheu- 
matism. 

Let us now consider the mechanism of causation as presupposed under 
these two suppositions. Fuller, who disregards almost entirely the effect 
of chill, quotes Headland with approval in respect to the chemical changes 
* which result in the production of lactic acid. His belief was that the starch 
of the food was converted into lactic acid through the natural operations 
of digestion and assimilation, and then combined with oxygen to form car- 
bonic acid and water, in which form it is thrown out of the system by the 
lungs. Anything which interferes with this oxidation of lactic acid must 
lead to its excessive accumulation. As Fuller disregards the influence of 
chill, he infers that the disease is usually due to causes which prevent this 
oxidation rather than to the non-excretion of lactic acid by the skin, or to its 
excessive formation in the primary or secondary processes of assimilation. 

The other authors who support this branch of the theory point to the 
chill as being a necessary factor in the retention, through defective skin- 
action, of the lactic acid, and perhaps also to the effect of the chill in pro- 
ducing an excessive amount of it, by deranging the primary assimilating 
or digestive process. 

In considering the more recent physiological work and its bearing on 
this theory of rheumatism, it will be well to speak a little in detail, but as 
briefly as may be, of the chemistry of lactic acid. Three kinds or forms 
of the acid have been shown to exist ; first, the lactic acid of fermentation, 
formed when saccharine or starchy matters ferment ; and secondly and 
thirdly two forms of acid which are distinguished by a difference of solu- 
bility and by a different optical reaction tested by polarization. Both of 
these latter are derived from muscular tissue, and may be obtained by the 
chemical manipulation of beef extract or juice. The fermentation lactic 
acid is not present in muscular tissue, and cannot be obtained from it, or 
be derived from the two other isomeric forms. The two others have re- 
ceived the names of sarcolactic and ethylene-lactic acids, of which the 



58 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

former is looked upon as most prominent and abundant, and is the one 
about which in this matter we are most interested. 

The presence of lactic acid in muscular tissues was discovered by Ber- 
zelius, and it was subsequently shown to differ from the ordinary lactic 
acid of fermentation, as above related. It seems that these tissues in all 
animals, immediately after death, however recent, exhibit an acid re- 
action, and it was this fact, as well as the possibility of obtaining the acid 
in considerable quantity from muscle, which led many authors to believe 
in its presence during life. It is to Du Bois Eeymond we owe the knowl- 
edge that the acid is non-existent so long as somatic life continues. 
"While muscle is alive and in a physiological condition it possesses a 
neutral reaction ; so soon as it dies the reaction becomes acid." Previ- 
ously the composition of muscular tissue had been studied in its dead 
condition, and it becomes of immense importance to distinguish between 
a " tissue which is yet living, though it may be separated from the living 
body of which it once formed a part, and one which has ceased to mani- 
fest the phenomena which it j:>ossessed during life." 

It would seem, therefore, that there existed in muscular tissue an amy- 
olitic or saccharine ferment, which during physiological action served to 
convert the nutritive material supplied by the blood into tissue, but which 
at the suspension of life wasted itself or turned aside to form lactic acid. 
The very first effect of the appearance of lactic acid in muscle, however, 
and in fact that which changes its reaction from neutral to acid, is the 
production of acid potassium phosphate by the decomposition of the al- 
kaline phosphate. This condition is rendered very probable, if we recall 
the facts pointed out by Lehmann and others, that this salt is ever pres- 
ent in all tissue-forming substances, or as C. Schmidt remarks, is essencial 
to supply the first basis for all new formations of tissue. 

It must be remembered that all these studies, which have recently been 
summarized and still further developed by Gamgee, have been carried out 
mostly in cold-blooded animals, as their muscles continue their vitality 
so much longer that fuller opportunities are afforded for careful study. 
Our conclusion, drawn from such premises, should therefore be duly 
qualified, and above all, the amount of acid, developed under the most 
favoring conditions, should be remembered as being actually very small in 
amount. The older authors, too, speak very confidently of the rapidity of 
the conversion of lactic acid received into the blood from ingesta, and also 
of that formed, as they supposed, under physiological conditions in the 



PATHOLOGY. 59 

muscles themselves. This conclusion is arrived at from the results of 
therapeutic experiments, where, after the ingestion of certain lactic acid 
salts, the urine becomes rapidly alkaline, containing undue amounts of the 
alkaline carbonates, of which the carbonic dioxide is supposed to result 
from the conversion of the lactic acid. 

However, by most authorities the presence of lactic acid even in the 
chyle of the thoracic duct and also in the blood is generally denied, and 
has certainly never been shown positively to occur, and this, too, even when 
its presence is acknowledged in the small intestine, as the consequence of 
the digestive or other changes in amylaceous or saccharine materials of 
the food. Still further, the presence of lactic acid is denied, or has never 
been proved to form a constituent of the lymph or venous blood return- 
ing from the muscles, which are supposed to manufacture it in such abun- 
dant quantities. It has not been claimed that under physiological condi- 
tions the conversion of lactic acid into carbonic dioxide or other products 
takes place, as do so many of the other nutritive or constructive and retro- 
grade transitions in the muscles themselves, and certainly this conversion 
cannot be claimed as the normal process for the lactic acid derived from 
disordered primary assimilative processes, as claimed by Todd and others, 
as the origin of the supposed materies morbi of rheumatism. 

It would seem, therefore, that in deriving the peccant material from 
ingested lactic acid, the source and the seat of its activity as a morbid or 
foreign product were separated by a space over which the acid does not 
show a capacity for overstepping. And this much at all events can be 
denied to lactic acid from digestion, as the initial factor in the production 
of rheumatism, however much may be laid at the door of other harmful 
matters of an unspecified nature, as referred to by Fuller, derived from 
the disordered primary assimilative process. 

Now, with regard to the lactic acid of the muscle — sarcolactic — it is 
claimed to be present or rather developed more rapidly and in greater 
abundance during muscular exercise, and it is to the accumulation of these 
products, as the experiments with frogs' legs show, that the exhaustion of 
the muscular irritability is due ; but how far the presence of this and 
similar products can explain the occurrence of fatigue, as claimed by the 
advocates of this more recent phase of the lactic acid theory, is a matter 
of much doubt. 

If these matters are not the cause of muscular fatigue, a very special 
piece of evidence that lactic acid is the cause of rheumatism is taken away. 



60 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The presence of lactic acid, as yet unproved, has been claimed as the 
materies morbi, and that it was rapidly developed there from the retro- 
grade changes of the exercised muscle — these being almost necessary pre- 
cedent conditions to the development of a rheumatic attack. If these 
matters cannot be shown to be the cause of fatigue, the evidence fails 
almost completely that their presence, and especially that lactic acid is 
the cause of the rheumatic phenomena. 

It is maintained that these products are ordinarily carried off and ex- 
creted or decomposed, but that chilling of the surface coincident with 
or following muscular fatigue prevents the elimination of the muscular 
products by the skin, which is thought to be one of the usual channels 
of escape. However, an analysis of sweat, either in health or in dis- 
ease, has failed to show clear evidence of the presence of lactic acid. 
The striking difficulties of examination, chiefly consisting in the difficulty 
of obtaining a sufficient quantity for testing,, and in the rapidity with 
which alteration in this fluid occurs; may well excuse an uncertainty on 
this point. 

The old notions of humoral pathology, especially such as are repre- 
sented by Todd, held that the peccant matter of the disease was excreted 
by the skin, and that this acid gave the reaction to sweat which is so 
often a prominent symptom of rheumatic fever. This idea and a single 
analysis of Favre furnish the only grounds for the belief in the presence 
of lactic acid in the cutaneous secretions. 

The next conception advanced in promotion of the lactic acid theory 
of rheumatism was the effort to prove that its symptoms could be de- 
veloped by the administration of this substance. The experiments of in- 
jecting lactic acid into the circulation or one of the cavities of the body 
have either proved to be failures or the results have not been conclusive. 
The exhibition of the acid by the stomach in the treatment of diabetes 
has been quoted by several as effective in producing the symptoms of 
rheumatism, and that the phenomena disappeared with the cessation of the 
use of the drug. This result is certainly very striking, and if it can also 
be shown that the acid enters the system, as such, thus to reach the parts 
principally affected in rheumatism, the theory must certainly receive its 
most positive element of support. 

It is also known that the rheumatic symptoms produced in diabetic 
patients by the administration of lactic acid disappear again, although the 
remedv is continued. This fact at once throws a strong doubt on the 



PATHOLOGY. 61 

cause of the articular phenomena, and certainly does not point very 
strongly to their being due to the ingestion of the acid. 

Still, I would submit that this item of proof is a very different matter 
from the statement of the theory as it is now held, viz., that the rheu- 
matic symptoms are produced by changes taking place in muscles as the 
results of exercise and the retention of these products from chilling of the 
surface of the body. 

The differences between the old lactic acid theory of Prout and Todd 
and this new belief in the mechanism of the disease have already been 
spoken of. No allusion has, however, been made to the fact that the 
other avenues of escape and elimination of the products of metamorphosis 
are unaffected by the chilling of the skin. The lung and the kidneys 
under the effects of the chill remain uninfluenced or are at least unre- 
strained, and are therefore, as we know, capable of assuming a compen- 
satory vicarious action, whereas in the diabetic patient in whom the ad- 
ministration of lactic acid is followed by rheumatic symptoms, these two 
avenues are especially interfered with as the results of the diabetic disease. 
In addition — and this is certainly a more important consideration — in the 
diabetic it is orobable that some of the organs — for example, the liver— are 
so interfered with that the primary as well as some of the secondary pro- 
cesses of assimilation are incapable of assisting in the decomposition of 
the lactic acid, administered as medicine, or even of producing entirely 
new products during the course of assimilation. Hence, lactic acid may 
accumulate, or be capable of producing effects in the diabetic which it does 
not possess in persons in usual health, and therefore the facts noticed in 
the abnormal condition cannot, I think, be taken as just conclusions to be 
drawn in relation to the rheumatic attack, for it is out of perfect health, 
so far as we can judge, that the supposed accumulation of lactic acid oc- 
curs when it produces oftentimes its most striking rheumatic phenomena. 

The Defects of this Theory.— In the strictures which have been ad- 
vanced against the lactic acid theory the argument is not intended to bear 
so much against what may be denominated the action of effete products, or 
at least to the mechanism of their accumulation in the system, or even their 
local action, so much as against the specific substance, namely, lactic acid. 
I do not think that the acid should be spoken of as the single offending 
matter to the exclusion of perhaps many others, which we may suppose 
can be produced by a similar mechanism — a mechanism which, except ac- 
cording to Fuller, is quite an essential part of this theory. 



62 

Lactic acid has, I think, received an undue prominence and has been 
placed in a position which, I have tried to show, it obtained probably 
through a mistaken chemical analysis. Prout's exaggerated conception of 
the occurrence of the acid probably led him in the first place to consider it 
as the materies morbi of rheumatism. He makes no mention of the earlier 
discoveries of Berzelius, and in no way traces any connection between the 
lactic acid of digestion and sarcolactic acid of muscular work. There is, 
in addition, but little unity between the earlier lactic acid theory of Prout 
and Todd and the later development of the idea of its production from 
muscular action and fatigue. It would seem, therefore, that having once 
been accepted as the peccant material, lactic acid has been continued in 
the role, although its source and the mechanism of its production have 
been entirely changed according to the later notions. It is difficult, there- 
fore, to view the matter as presenting in any way a consistent face ; the 
two ideas are almost as dissimilar as if they related to an entirely new sub- 
stance. The latter does not receive any support from the former. 

It may not be thought consistent to object to lactic acid and at the 
same time refer to other unknown, unmentioned materials of not dissimi- 
lar origin. "While at first glance this may seem a just criticism, I do not 
think on examination it will turn out to be so. The objection against 
lactic acid is on account of the very slender proof of its presence, so slen- 
der as to be almost wholly wanting, and moreover it is a very different 
matter to object to the specific substance and yet to accept the theory of 
the mechanism of its production, which, so far as shown, is capable of the 
accumulation of many other substances in addition to itself. Much better 
to rid ourselves of the single definite product and accept a host of un- 
known materials with a probable and consistent cause for their formation, 
even should that cause be the same as for the origin and accumulation of 
the single product, namely, the lactic acid. I judge that it is not by any 
means so desirable to know the exact peccant material as to ascertain the 
means of its development. It is the desire to correct the abnormal pro- 
cess, rather than to neutralize, chemically or otherwise, the abnormal mat- 
ters developed by the process, which controls our action and must direct 
every correct pathological research. 

In the old humoral pathology, and in the even older theocratic concep- 
tions of disease, all attention was directed to the discovery of the poisons 
which were productive of diseased action. Thus there was all the time 
search being made for the offending material, which must be expelled or 



PATHOLOGY. 63 

neutralized ; according to still older notions, it was a devil to be cast out, 
and whether called a humor or a devil, it was very much the same thing. 
The one idea was but a continuation of the other. 

The conception that disease is but a deviation from the normal physio- 
logical type of fiction, either by excess or deficiency, is of comparatively 
recent origin, and its essential truth does not as yet seem sufficiently 
widely extended. Although many abnormal products of diseased action 
may be present, or even normal ones may vary by excess or deficiency, it 
is scarcely sufficiently understood as yet that these products are neither 
the disease nor the cause of the disease. A very great deal of wasted 
effort has been expended, both pathologically and therapeutically, in ex- 
plaining and combating the presence or absence of various materials 
which had far better be employed in considering the cause and the nature 
of deviated function. 

So it is with rheumatism. Whether we lend support to any one of the 
various conceptions of its nature — whether we consider it a simple local 
disturbance (now entirely discarded), or a zymotic disease, or produced 
by the action of cold on the vascular supply of a part, or (what is much 
allied to this idea) that it is a vaso-motor neurosis, we cannot too strongly 
endeavor to disassociate our ideas from the products of diseased action, 
and concentrate them on the deviated function which leads to their pro- 
duction. Even should lactic acid be shown to cause invariably rheumatic 
symptoms, when injected into a joint, or that it was always present as the 
result of deviated action, our study must be to correct the process which 
produces it. The production of lactic acid has its own cause, and it is to 
the study of this cause we should devote our attention. 

Again, these ideas of physiological pathology, as applied to the study 
of rheumatism, seem particularly appropriate, and apply themselves in 
harmony with its peculiar characteristics. No disease bears so little the 
impress of being a poison-disease. Out of good health suddenly come 
pain and fever with local phenomena. It comes under conditions of good 
hygiene with striking frequency. No pathological condition so little leads 
us to think of any deleterious matter absorbed into the body, and the 
lapse of time between the exposure to an apparently efficient cause and 
the onset of its symptoms seems too short for the accumulation of pro- 
ducts of an irritant or poisonous nature to take place, at least in a quantity 
sufficient to produce such striking effects and yet to escape detection and 
remain through centuries unknown. Besides, the local phenomena are 



64 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

often very fleeting in character and, when durable, very unlike those we 
usually connect with the results of an irritant, whether of local or general 
origin. 

Another fact should be alluded to in discussing the specific substance 
supposed to be productive of rheumatism. According to* the later lactic 
acid theory, this substance takes its origin in waste products of muscular 
exertion, and is supposed therefore to exist in the muscles themselves. 
But it is in the articulations that the symptoms first and most conspicu- 
ously manifest themselves, and although in muscular exercise the joints 
necessarily participate in functional activity, yet nothing has been shown 
in connection with articular processes, normal or pathological, which di- 
rectly leads us to think that lactic acid is produced in their structures. 
Although we have no difficulty in tracing the entrance of the lactic acid irri- 
tant into the synovial cavities, yet I think we ought to expect to find a 
preponderance of irritative phenomena in the place where the peccant matter 
took its origin. Granting, therefore, due weight to the fact that the 
functional activity of the joints renders them perhaps especially susceptible 
to diseased action, still I think we should expect to see the brunt borne by 
the muscles which according to this theory produce the irritant material. 
And while functional activity of the joints helps to explain their partici- 
pancy in the rheumatic phenomena, it does not contribute anything to 
showing that lactic acid is the morbid matter which produces rheumatism. 

Infection Theory. — Lastly, let us examine what is the conception of 
rheumatic disease which has been formulated in accordance with the terms 
and requirements of the Germ Theory. 

This new theory of the pathological nature of rheumatism has been 
called the infectious. Its claims have recently been stated very clearly by 
Miiller, of Zurich. The idea of the infectious nature of the disease was 
pronounced more than twenty years ago by Hirch, and others have followed 
him in his views. Miiller states that acute articular rheumatism is a 
general disease, which is due to a specific excitant. The joint affections 
are only a symptom and depend on infection. The complications are ex- 
plained by the same cause. Articular rheumatism belongs, therefore, to 
the febrile infectious diseases. 

It will at once be perceived that this theory differs from the usual ones 
in vogue in attributing the cause, not to something developed within the 
organism, but to an infectious material imported from without, which 
either by its presence or by its development within the system directly 



PATHOLOGY. 05 

produces the phenomena of the disease. Further, this cause is not cold 
which serves as the foundation of most of the other theories of its 
pathology, or at least this agent can only be regarded as a determining or 
exciting cause of the disease. In relation to the influence of cold on 
rheumatism, Hirch, in his medico-topographical studies, claimed to have 
shown that this disease was absent in localities especially affected by 
diseases pre-eminently due to this morbific agent, while in other places 
where the influence of cold or changes of temperature or climate were but 
slight that rheumatism was especially prevalent, and that this disease con- 
cerned "a specific acute infection, which perhaps has similar relationships 
to rheumatism as influenza has to catarrh." 

The occurrence of so-called epidemics of the disease, to which allusion 
has already been made, is depended upon to show a probability of its in- 
fectious character, or at least its similarity to other diseases of an un- 
doubted infectious nature. The age at which rheumatism most frequently 
makes its appearance has been pointed to as the same time of life which 
favors typhus and typhoid fevers. 

Not only in the apparent etiological relation of the disease, but likewise 
in its clinical relations, Miiller, in particular, claims that there is a re- 
semblance to infectious diseases. An exact study of a large number of 
cases, he says, will show that rheumatism does not commence within a 
few hours after an exposure to which its origin is usually attributed. In 
other words, it is' not a disease without prodromes, but that often for many 
days the usual febrile phenomena precede the development of the articular 
symptoms. Ordinarily, however, this condition is so slight that no note is 
taken of it. This fact, he claims, shows that acute articular rheumatism 
is not a disease which owes its first existence to local phenomena, or is 
due to the retention or development of lactic acid. The poison must be 
an element in the blood, as it is in other infectious diseases, and that the 
infectious element seeks the joints pre-eminently because here it finds the 
best condition of its growth and development. 

The occurrence of rheumatism subsequently to attacks of scarlet fever, 
as well as other infectious diseases, is pointed to as favoring the view of 
the similarity of their nature. Likewise the occurrence of articular 
disease of a similar character to the rheumatic synovitis, as a concurrent 
symptom in such purely infectious diseases as pyaemia, septicemia, and 
puerperal fever, is strongly insisted upon. 

The complications of rheumatic fever, namely involvement of the 



66 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

serous membranes, the pleura, the pericardium and endocardium, are of 
the character found in other infectious diseases and quite unlike those 
occurrences in a simple inflammatory condition. 

The occurrence of hyperpyrexia is similar to that coming in other in- 
fectious diseases, such as erysipelas, intermittent and typhoidal fevers. 

Finally, Miiller points to the evidence of pathological anatomy in 
support of his theory — the occurrence of parasitic organisms, which were 
found in a patient who died of acute articular rheumatism, in whom small 
multiple abscesses were present. This is the evidence of v. Keckling- 
hausen in 1871. Fleischhauer, in 1873, found micrococci in miliary 
abscesses in the lungs, heart, kidneys, and in almost all the muscles, in 
a patient dying of a disease having the ordinary clinical features of articu- 
lar rheumatism. 

Eberth (1875) has likewise shown a parasitic character for the endo- 
cardial changes in a number of cases. Koster (1878) believes that the 
endocarditis of this disease depends on micrococci-emboli of the valvular 
capillaries. 



CHAPTEK Y. 

DESCRIPTION AND COURSE OP THE DISEASE. 

Acute Rheumatism : the Prodromal Interval; Chill; Fever; Pain; Aspect of Face • 
General Bodily Condition ; Skin ; Pulse ; Temperature ; Digestive Functions ; 
Urine ; Sleep ; Delirium ; Menstrual Function ; Epistaxis ; Course, Duration, and 
Severity; Result. — Subacute Rheumatism: Its Distinction from other Grades 
and Forms. 

Acute Rheumatism. 

The Prodromal Interval. — Almost the first question that occurs in 
studying this part of our subject is the length of time elapsing between 
the application of the cause and the onset of the characteristic symptoms. 
In all infectious diseases this interval is one of great importance, and is 
called the period of incubation. In rheumatic affections I judge it to be 
incorrect to apply this term to the period here alluded to, for although 
the cause of rheumatism is unknown, we are sure that it is not a specific 
poison introduced into the system from without, as in the case of the in- 
fectious or contagious maladies, and there is no materies morbi which 
requires time for its development by generation, as is supposed to be the 
case in this class of diseases. This interval in rheumatic affections is 
therefore of less importance, and is allied in its essential characters to the 
period which precedes, for example, the development of pneumonia, or let 
us say, between the receipt of an injury and its consequent inflammatory 
or febrile phenomena, although this latter instance is not a precisely par- 
allel one to rheumatism. Dr. Hay garth (1805) is the first writer who I 
find has spoken particularly of this question. He calls it the "latent 
period " and in twenty-one cases the time between the exposure to cold, 
which he considered the efficient cause, and the commencement of the 
fever, varied from half an hour to ninety-six hours. 

While the determination of this interval preceding the commencement 
of fever may be a matter of some interest, a knowledge of it is not really 



68 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

valuable in affording us information either as to the cause or the nature of 
the disease, in which respects the incubation period of infectious and con- 
tagious maladies is so conspicuously of use. And then, too, there is no 
agreement as to what particular symptom is to be regarded as the real 
commencement ; some would think of the preceding malaise, others would 
refer it to the febrile phenomena. 

The older writers, following Haygarth, nearly all concerned themselves 
with observing the length of this period, and in accordance with their be- 
lief of the true cause of rheumatism it afforded a proper subject of study. 
It was a simple matter to note the elapse of time between the application 
of the cause — and it was generally held by them to be cold or some atmos- 
pheric influence easy of determination — and the development of the first 
symptoms. "While most of these writers agree with the figures of Hay- 
garth, or quote approvingly his statement, quite a number of observa- 
tions are recorded of a prolonged period or a delayed appearance of the 
disease ; it is quite natural that such should be the case so long as the 
opinion held in force is that only one set of influences were productive of 
the disease. Cases were noted also in which no exposure to the then 
nearly universally recognized causes was discoverable. 

Later writers have been much more guarded in expressing opinions on 
the duration of this interval, and very justly so. Since the nature and 
causes of the malady are still in doubt, it is manifestly improper to speak 
with confidence of the length of the period between the development of 
the cause and the onset of the first symptoms. Even granting that expo- 
sure to certain influences is an efficient cause for development of a rheu- 
matic attack — certainly it does not always thus result, neither is it always 
a precedent circumstance — it is evident that other changes may be acting 
than the simple exposure, for example, a wetting, antedating the exposure ; 
the latter, therefore, can only be regarded as a concurrent cause of the 
attack. The true and just statement, the only one warranted by our 
knowledge of the disease, is that the onset of the attack, evidenced by 
the commencement of the fever, is preceded by some trifling symptoms, it 
may be malaise, disturbance of digestion, or vague general or local pains, 
lasting for a variable period of time and differing greatly in their inten- 
sity. This period rarely exceeds a week, and on the other hand is equally 
rarely less than a day. 

Chill. — The next phenomenon in the development of a rheumatic attack 
is the appearance of a chill or rigor. From a comparison of a large num- 



DESCRIPTION AND COURSE OF THE DISEASE. 09 

ber of cases, both of my own and others, it is evident that a well-marked 
or severe chill is not a conspicuous symptom in the commencement of 
acute rheumatism. In about one-third of such cases only is it a suffi- 
ciently well marked or noticeable feature to be recorded or alluded to, at 
least by the patient. The more rapidly the onset of the attack succeeds 
exposure, supposing this circumstance to have preceded the development 
of the disease, the more frequently the chill is noticed, and likewise is the 
symptom more marked in intensity. In other cases where the develop- 
ment is slower or without severe or perhaps discoverable exposure, the 
chill is more generally absent or is more properly described as a chilly or 
creeping sensation ; frequently in these latter cases the rigors, always 
slight in degree, are repeated. 

Fever. — Probably immediately or very shortly after either the chilly or 
creeping sensation, the bodily temperature is increased and afterward 
falls to rise again subsequently to the succeeding creep or rigor, if such 
occurs. The opportunities for observing the temperature oscillations in 
the stage preceding the onset of acute attacks are not very numerous, for 
the patients are not usually under observation, and they have not been 
extensively availed of or recorded. Such, however, have been the results 
of my own experience, and they correspond with those of a few others. 
There is nothing characteristic in these thermometric changes ; they are 
only what would be expected in connection with these prodromal symp- 
toms. The longer the precedent stage is drawn out and the more pro- 
nounced the symptoms in connection with it are, the greater is the ten- 
dency to these slight oscillations of temperature. 

Whatever may chance to be the duration or the character of this pre- 
cedent stage, or if entirely wanting, the important rigor, whether slight 
or well marked, which announces the immediate onset of the attack 
ushers in the fever, which thenceforward slowly or rapidly rises and be- 
comes continuous. The initial rigor of the onset is rarely of a marked 
character, often less pronounced in its subjective phenomena than the sen- 
sation of cold from the exposure or wetting, so commonly the cause or 
precedent of the rheumatic attack ; its objective phenomena are also 
usually of but slight intensity; pallor of the surface, coldness of the 
extremities and slight shivers, without cyanosis or convulsive movements 
only are noted. 

The fever is most generally of gradual development, and rarely is a 
high fever heat attained before the second or third day after the real 



RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

S6fl th:it a BUddeD rise lakes place, while 
usually the temperature mounts up slowly but pretty continuously. 

..- The pains, usually present in the precedent stage, are vague, 
flitting, or trans Doming concentrated, so to speak, in one or more 

; joints which previously were especially painful are apt to be first 
. before the onset of the fever, one or more joints 
are the seat of aching, and these subsequently are the ones to become 
painful, so that we have the manifestation of a continuous development of 
the joint affection more or less suddenly accelerated by the accession of 
the fever. The more rapid the onset of the attack the earlier the joints, 
alone or principally, become the seat of severe pain. After the accession 
of fever and the marked concentration of pain in the joints, the fleshy 
parts of the limbs, as well as other muscular areas still continue painful, and 
nsation of these parts not infrequently increases along with the artic- 
ular pains, although usually this feature is less marked or at least less 
complained of than the supreme suffering of the articulations. 

With the pain, or soon after it, comes heat, swelling, and redness of the 
affected joints. Of these three symptoms, one or more are generally pro- 
nounced, or it may be all three, and are, in accordance with their posi- 
tion, more visible in the joints the least covered with overlying tissues, as 
in the extremities, which are the articulations more commonly affected, 
although the same conditions obtain in joints, such as the vertebral, 
though concealed from observation. In the superficial joints we are able 
to assure ourselves that the swelling not alone affects the tissues around 
the joints, but is due, in part and it may be largely, to fluid within the 
articular capsule. This condition is evidenced by fluctuation, which is al- 
ways, in this stage at least, of a tense character, and it can be detected only 
by firm pressure, partly because of the swollen and thickened tissues over- 
lying the joint and partly, perhaps principally, because of the necessary 
tight spanning of the joint capsule as it yields before the fluid accumulat- 
ing within its cavity. In fact, so characteristic is the tense fluctuation of 
an oncoming articular inflammation, or one well developed, that a boggy 
or loose condition of the capsule becomes an evidence of a lessening or 
cessation of the articular inflammation and the beginning of an absorp- 
tion of the fluid. The tense and tearing or rending pains of acute rheuma- 
tism, apart from their production as in ordinary inflammation, are thought 
to be greatly increased by the stretching of the capsule of the joints by 
the accumulating fluid within them. And it is generally to be observed 







DESCRIPTION AND COURSE OF THE DISEASE. 7l 



that joints which become greatly distended are, during the stage of acces- 
sion of the disease, more painful than those less swollen, and it also 
happens that the greatly distended joints, whose ligaments become relaxed, 
are during the retrogressive stage less uncomfortable than those equally 
inflamed but not stretched by inflammatory exudation. 

The pain of the inflamed joint is probably rarely or never equalled by 
any other form of articular inflammation except gout. The dread expressed 
by the patient of the slightest touch of the examining hand, the contact 
of the clothing or even the imperceptible shaking of the bed by the move- 
ment of any one in the room is quite characteristic, and at the same time 
expressive, of the suffering endured and the severity of the disease. 
Generally, at this early stage of the attack, the patient is in bed, confined 
there more by the disinclination or impossibility of rising and dressing, 
owing to the pain produced by movement, than from the severity of the 
general symptoms. The disease has been gradually advancing, the malaise 
has been marked, but not sufficiently to induce the patient to remain 
in bed, but retiring to sleep for the night he is either awakened by the 
increasing pain or on attempting to rise in the morning finds it impos- 
sible or so painful as to be deterred from the attempt. In other cases the 
accession of pain, and with it the fever, comes on by day, surprising the 
patient while dressed. The efforts to remove the clothing are found so 
painful that undressing is not undertaken until the disease is well 
advanced. Days and nights are not infrequently spent resting in a chair 
or lying on a couch or bed, until it becomes necessary to cut the clothing 
away and put the patient to bed properly, and break up the suffering vigil. 

The aspect of the patient is expressive of suffering and a dread of be- 
ing approached or moved. He acts as though concealing a treasure 
under cover, which must not be moved or touched, and if compelled to 
change position the whole body is made to revolve around the painful 
joint, rather than disturb the affected member. When allowed to re- 
main at rest the face and body assume the air of semi-comfort and intense 
quiet, but withal there is an air of vigilance. This constantly maintained 
condition is productive of a strain and is capable of developing a nervous 
irritability, which necessarily must add to the characteristics of this stage, 
and also tend to the increase of the general symptoms, apart from the 
idue advance of the disease. The nervous effects vary with the innate con- 
stitutional peculiarities of the patient, and become increased or decreased 
proportionately to these conditions. 



72 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Aspect of Face, — Otherwise the appearance of the patient, especially 
the face, is not indicative of the severity of the disease, and in respect to 
the fever, does not ordinarily show in this early stage the changed aspect 
proportionately to the febrile movement present as is exhibited in other 
diseases. Except after movement, which from the pain endured would 
induce flushing of the face, no redness or suffusion permanently remains. 
Paleness or the sallowness of anaemia are very common, but these are to 
be looked upon as antecedent characteristics rather than peculiarities of 
this stage of the attack, except, of course, so far as their causes may be 
considered as equally a cause of the rheumatism ; this opinion is held by 
some writers. In a large number of cases the color and aspect of the face is 
one of health, altered by acute suffering. An appearance of the face, which 
I have frequently noted, but which I do not find is alluded to by others, 
is a turgid, more or less cyanotic one. The condition is one which from 
its causation is brought about only in the severer cases, where many joints 
are affected and the pain very severe, or even in the slighter cases during 
necessary movements or the examination of the patient's physical condi- 
tion. The turgid face or cyanosis is produced by the voluntary or invol- 
untary efforts in attempting to hold themselves still, to render the painful 
joints or members immovable, and to lessen the pain due to slight general 
movements of the trunk or members, produced by the respiratory move- 
ments. The cyanosis is entirely apart from, and occurs independent of 
any cardiac or pulmonary complications and the pains which accompany 
these lesions. The phenomenon bears the same character as the similar 
condition seen in any one making a strong or prolonged muscular effort, 
and is like, though perhaps less marked, to what is witnessed in a patient 
during the setting or dressing of a fractured bone. In this case the 
efforts to render the injured member immobile cause an involuntary mus- 
cular strain which quickly results in a turgid darkened face. 

This phenomenon is, so far as concerns the general condition of the 
patient or the course or characteristics of the disease, a matter of little 
moment, although one which is, I believe, rarely absent. Its importance 
arises from its furnishing an indication of the degree of suffering experi- 
enced by the patient. Of course its production is easy, but not likely to 
be simulated by a malingerer, while the other facial aspects and contor- 
tions of pain are familiar, and are but too ready to make their appearance 
as attestation to the degree of suffering endured. In those patients who, 
without feigning or. meaning to exaggerate their agony, frequently mislead 



DESCRIPTION AND COURSE OF THE DISEASE. 73 

us, we have a ready test by which to graduate the anodyne or narcotic 
remedies, if this condition of the face is carefully noted under proper 
circumstances for proving its reality. 

General Bodily Condition. — The general surface of the body is warm 
but not very hot ; it never gives the sensation of dryness and burning heat 
which are found in other diseases attended with an equal elevation of tem- 
perature. In severe, and even in moderately severe cases, accompanied 
by great pain in the articulation, the surface is bathed in perspiration, 
often very profuse in amount. The patient in this condition gives off an 
acid odor and the skin secretion is of acid reaction. It would seem, at 
least in many, that as the temperature increases, the sweating becomes 
more profuse, and it is certainly true that the more joints involved and the 
more severe the pain, the greater is the amount of this secretion. 

Skin. — Sudamina make their appearance often in great abundance and 
in successive crops. Miliaria and other forms of skin eruptions are not 
infrequently witnessed. 

Pulse. — The pulse may be unaffected, but generally increases in fre- 
quency from the beginning, and varies from 80 to 100 in moderate cases, 
and in severe cases runs up to 120 or more in the minute. Its character 
differs very greatly in different patients, but maintains in general the same 
characteristics throughout the same attack. It is generally full ; it may 
sometimes be found hard but much more commonly is soft and compres- 
sible. In the later stages of prolonged attacks it always becomes soft, 
small and feeble in proportion to the degree of ansemia. In complicated 
cases or where rheumatic visceral localizations occur during the course of 
an attack, the pulse is very liable to become much altered in character, 
and its frequency is subject to great variations on the accession of new 
articular involvements. 

Temperature. — The temperature in all forms and in every grade, except, 
perhaps, in chronic rheumatism, is raised above the normal ; in general it 
is found to range in different cases according to their severity within the 
limits of 99.5° F. (37.5° C.) and 104° F. (40° C). Cases occur where the 
heat is so little elevated that careful observations are required, frequently 
repeated during the day, to detect any thermic excess, and on the other 
hand cases of hyperpyrexia are not infrequently noted in which the upper 
limit here given is far exceeded. The rise of temperature is generally a 
gradual one, and the oscillations during its course, except those due to 
fresh localizations, are not striking. The termination of the febrile stage 



74 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

is not marked by any crisis in the temperature curve, but the bodily heat 
gradually returns to the normal with greater or less rapidity, and more or 
less irregularity, proportioned to the regular course of the disease. 

Digestive Functions. — The digestive organs and functions may in the 
slighter cases remain intact, and even the desire for food continue un- 
abated, eating being interfered with only by the painful efforts in handling 
the food. In the severer cases the appetite is lost, the tongue coated with 
a moist, whitish fur, and often heavily ; vomiting is rarely present and not 
characteristic ; the bowels are usually confined and their evacuation greatly 
hindered or prevented by the pain of movement. 

Urine. — The urine is acid, high-colored, and scanty ; it lets fall abun- 
dance of dark uric acid products, has a high specific gravity, and in un- 
complicated cases is free from albumen. Patients often retain the urine 
voluntarily a long time to escape the pain incident to voiding the bladder. 

Sleep. — Sleep is greatly interfered with or entirely prevented by agoniz- 
ing pains, and is often the greatest source of complaint by' patients. This 
condition, however, varies during the course of the attack ; in the initial 
stage, before or during the effusion into the joints, the spontaneous agony 
prevents a moment's rest ; after the full development of the articular in- 
flammation, if a comfortable position can be maintained, sleep is often 
ample, and is interrupted only by the pains incident to disturbance or 
movement of the articulation ; in the later stages of prolonged attacks the 
weary aching of the limbs becomes a source of great wakefulness. 

Delirium. — Delirium is rarely present and is by no means a character- 
istic feature of the disease, even when the higher grade of febrile heat is 
reached. The mind is clear throughout the attack, except in cases of 
cerebral complications. Occasionally a slight wandering of the intellect 
is noticed on the occurrence of exacerbations or complications, or in ner- 
vous patients or those rendered irritable by the suffering. 

Menstrual Function. — The menstrual function is usually interrupted or 
the flow is delayed in its appearance by an oncoming attack of rheuma- 
tism. If the fever commences but a very short time before the period, a 
brief or incomplete menstrual flow takes place ; a well-developed or severe 
attack usually entirely prevents the flow and alters the rhythm of its return. 
I have seen the menstrual period evidenced during moderately severe at- 
tacks by the discharge lasting for a few hours or during one day. The 
menstrual blood in these cases was very thick, and of a black color ; in 
these attacks, when promptly recovered from, the next menstrual period 



DESCRIPTION AND COURSE OF THE DISEASE. 75 

returned in less than the usual time, but with the habitual character- 
istics. Occasionally it is profuse, if uterine disease exists. 

Epistaxis. — Epistaxis is a phenomenon not uncommon in acute rheu- 
matism ; it occurs not at the beginning but coincidently with some im- 
portant new localization of the inflammation and even perhaps more fre- 
quently at its remissions. It has been thought that certain drugs, as 
quinine and digitalis, have an influence on its occurrence. It is, however, 
without significance in relation to the nature or course of the disease. 

Course, Duration, and Severity. — All varieties in the grade of severity 
of the disease are met with, and are classed accordingly as acute and 
subacute cases. In some, the general and local symptoms are very slight 
and interfere but little with the health of the patient affected. In others 
the local mischief, either in its severity or extent, is greater, and the 
general disturbance of health is proportionately augmented. In others, 
again, the disease, commencing even mildly, may attain a severity which, 
from the degree of fever and the intolerable agony, seem to threaten life. 

After continuing for a varying period the disease very nearly always 
ends in recovery and a greater or less restoration to health. The course 
which any given case pursues is an indefinite one and without any recog- 
nizable type. The mild case may continue its course in the same grade 
through weeks, or may be prolonged by the involvement of new joints and 
i renewal of the inflammation in joints previously affected during the 
same attack. The mild case may become a severe one, by numerous 
oints becoming attacked simultaneously or by any or all of the many 
isceral complications. While mild cases, as a rule, end more rapidly 
han severe ones and a good state of health returns sooner, still the actual 
heumatic symptoms may be continued in their subacute form, without ex- 
cerbations or complications, as long as in the more severe cases ; the re- 
urn to functional activity of the joints and to general health is always 
aore rapid than in severe cases where the affection has remained for a long 
>eriod and at the same time has been severe. The visceral complications, 
hile they do occur in mild cases, though perhaps not as frequently as in 
Liose of higher grade, do not seem to be as severe in the former as in 
le latter, although their permanent organic changes in the organs in- 
olved are just as lasting in the mild cases as in the severe ones. 

A case which at its beginning exhibits high fever and great pain may 
uddenly mitigate in its severity and even promptly recover. It is these 
ases which are spoken of as abortive cases and which have been so mis- 



76 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

leading as to the results of treatment and so confusing to statistics. The 
initial severity yielding so promptly under the use of a particular drug 
or plan of treatment has been placed to the credit of the therapeutic 
agency, and this result has but too frequently not been confirmed by sub- 
sequent experience. 

The cases in which the fever gradually increases to a high grade and 
in which joint after joint becomes involved without the complete cessation 
of the process in the articulations first affected, are more generally apt to 
be the prolonged and severe ones — severe from long impairment of the 
general health, and from their visceral, especially cardiac, complications. 

However, cases which but too often present little favorable appearance 
for rapid recovery end quickly and leave no bad results, articular 01 
visceral, behind them, and, on the other hand, cases seemingly promising 
to be of short duration have their course, interrupted by exacerbations 
and relapses, greatly prolonged and leave behind a residuum interfering 
with articular functions or a susceptibility to the renewed occurrence oi 
inflammation, or even worse, a damaged heart or lung. 

Result. — Death rarely results from uncomplicated acute rheumatism, 
and when it comes, the temperature shortly preceding this event rises to 
an extreme elevation. In fact, a sudden rise beyond 106° F. (41.1° C.) 
is pretty surely fatal, and is rapidly followed by death unless checked by 
therapeutic means or quickly lessened spontaneously. The complications, 
their nature, course, and influence on the general symptoms, will be re- 
ferred to separately, later. 

Subacute Rheumatism. 

The classification or distinction of certain cases as subacute, is one 
that is not used among German writers, and but little among the French. 
In England the designation is much more common, but less so than with 
us. Among the older writers the use of the word is scarcely, if at all, to 
be met with, and it has sprung up comparatively recently to meet a demand 
for a ready and brief method of distinguishing between the different 
grades of rheumatic attacks. For this purpose and in this sense the term 
is a very proper and useful one and has met with general acceptance. 

Whatever may be the views held of the pathological relationship be- 
tween acute rheumatism and the chronic or muscular forms of the disease, 
it is clear that the affection intended to be designated under the head oi 



DESCRIPTION AND COURSE OF THE DISEASE. 77 

subacute is that which is allied to acute rheumatism or rheumatic fever 
or that spoken of by the Germans as polyarthritis rheumatica. It is 
proper, therefore, that a term now so frequently in use should have its 
range carefully pointed out, and that it should be fully understood 
whether we mean by it cases which pursue a more or less definite course, 
within the very wide range which every case of rheumatism has, and are 
characterized by the presence or absence of certain symptoms or compli- 
cations, or whether it is intended to indicate merely mild cases of the acute 
disease as distinguished from the chronic forms, or whether also it is 
used for mild cases of every form of the collective set of symptoms 
grouped under the head of rheumatism. In a disease like rheumatism, 
where the line of demarcation between the various principal groups is as 
yet vague and uncertain, it becomes a matter of still greater difficulty to 
distinctly outline the boundaries of a sub-group and to enforce uniformity 
of designation. 

In the present use of the word, the most extended uniformity among 
both writers and observers obtains in its application to conditions present 
during the stage of abatement of the symptoms as frequently seen after 
acute attacks. After the fever has subsided, but not entirely gone, the 
pains are lessened but yet are aggravated by movements and show a 
tendency to redevelop, the swelling has not subsided, while the periar- 
ticular thickening and the immobility of the joints still exist, the cases 
which previously exhibited severe symptoms are said to have assumed a 
subacute form, and it is under these conditions that most generally 
rheumatic attacks find their greatest prolongation and exhibit their most 
stubborn resistance to treatment. 

Many cases, however, make their appearance and continue throughout 
their course as subacute, although liable to aggravation, or more or less 
temporary exacerbation of their symptoms, and it is concerning these 
cases that the importance of a correct designation of the term subacute is 
of interest. Many maladies, as well as other rheumatic affections now 
distinctly separated from acute and subacute rheumatism, have been 
grouped under the head of subacute cases, and have proportionally 
warped the essential point of view from which they ought to be regarded. 

Of these it is not necessary to speak of many cases of slight, perhaps 
forgotten, injuries of the joints which run a course without active symp- 
toms and which, from improper treatment, as well as the mechanical alter- 
ations of structure, become indefinitely prolonged ; these are but errors 



78 

of diagnosis. Other cases, as those of rheumatoid arthritis and certain 
cases of chronic gout, previous to the time of their true nature becoming 
known, were spoken of as subacute rheumatism. For these and other 
reasons, perhaps partly from conditions inherent to the grade of the dis- 
eased process, it has been customary to speak of subacute attacks as 
being essentially prolonged, and as showing a less tendency to terminate 
promptly and thoroughly in a return to health and normal conditions, than 
a rheumatic attack which has exhibited a greater activity of its phenomena. 
Hence, not unfrequently subacute cases have been spoken of, and are still 
regarded as having a nature midway between acute cases and those of a 
chronic character, and being rather allied to the latter than to the former. 

While it may be true that subacute cases have a greater duration than 
acute cases, this characteristic is not part of their essential nature and is 
not due to a stronger alliance with chronic rheumatism. This phenome- 
non of their course is apparently dependent on another cause. Subacute 
cases do not always have a prolonged course ; many of them, mild through- 
out, end definitely, and the patient returns rapidly to health and normal 
conditions. 

Not a few instances of subacute cases occur in otherwise perfectly 
healthy persons, never the subjects of a pronounced rheumatic attack. To 
these cases but little attention has been given, and it is, in fact, not wel- 
comed by the patients themselves, if their medical adviser attempts to 
apply the name rheumatic. A strong, healthy person spurns the idea of 
being rheumatic — and spurns with it even more vigorously the physician 
and his unwelcome diagnosis. Such cases, in the few instances I have 
been able to study, generally to the patient, under a different name, have 
been attended with many of the symptoms, very much reduced in grade, 
found in moderately severe attacks. The history shows an exposure to 
some one of the causes to which a rheumatic attack is frequently traceable, 
and after a varying lapse of time, often but very short, preceded or not by 
antecedent discomforts of a very mild grade, pain occurs, vague and 
wandering, in one or more groups of muscles, or perhaps affecting one or 
other of the limbs, and a little later a joint, usually of the same member, 
becomes the seat of especial pain, of higher grade, or at least more notice- 
able than the general pain which precedes it ; rarely is the involvement, 
either of the members or the joints, bilateral or symmetrical. With this 
symptom the feverishness is developed. This phenomenon is of slight 
grade, proportionate in every respect to the mild local affection, difficult 



DESCRIPTION AND COURSE OF THE DISEASE. 7 ( J 

of detection, and is not accompanied with any acceleration of pulse ; in 
fact, an acquaintance with the personal peculiarity of the patient is essential 
to the recognition of the very slight disturbance of the normal con- 
dition of the circulation. 

Such a condition is one of very small importance, and for which the 
advice of a physician is rarely sought ; perhaps even it is not worthy of 
a name, but if a name is to be applied the term subacute rheumatism 
cannot be denied to it. It is an acute rheumatism in miniature. Attacks 
of rheumatism, however, occur in which the disease throughout, at all its 
stages, assumes a subacute character, and in which the disability and even 
the sufferings of the patient are very considerable. It is for the designa- 
tion of this form of the disease that the term finds its most useful and im- 
portant application. 

For entirely unknown reasons, some patients after exposure or the 
application of causes usually recognized as productive of acute rheumatic 
attacks, exhibit symptoms of the disease in a milder form. There is 
pain and tenderness of the joints, very commonly swelling, but rarely 
redness. The febrile phenomena exists only in their lowest grade, or are 
entirely wanting. This condition persists for a greater or less period of 
time, and often quite as long as a prolonged severe attack. The duration 
would seem to be increased in a manner similar to that seen in not a few 
other diseased conditions of a low type of activity, and perhaps also be- 
cause such attacks, demanding neither active remedial measures nor ex- 
treme, or even prudent care, become protracted through the want of both. 

After an indefinite course, the attack ends in convalescence and a re- 
turn of normal functions to the articulations involved. That such attacks 
are of the same nature as acute rheumatism is but too frequently evi- 
dencd by their assuming a high grade of severity through a gradual in- 
crease of the previously existing symptoms, and again sinking, to be con- 
tinued in the subacute form. These cases are not instances of either 
rheumatoid arthritis or of chronic gout, with exacerbations such as both 
of these diseases are liable to, because after a prolonged duration the 
joints involved do not become altered, as almost constantly results in each 
f these forms of joint affection. Besides, neither rheumatoid arthritis 
nor chronic gout, once fully established, subside so completely that the 
oints exhibit subsequently no deviation from the normal, as is so fre- 
quently seen in these cases of subacute rheumatism. 

Again, attacks of subacute rheumatism are not rarely repeated again 



80 

and again in the same person without, after the subsidence of the last 
attack, the joints exhibiting any more permanent alteration of their form 
and structure than after the first attack. In fact, it would seem that a 
severe paroxysm predisposes or increases the susceptibility of a patient to 
renewed attacks, repeated at frequent intervals and from slight causes, of 
a subacute form of the disease. Frequently, too, the subacute attacks 
are seen to occur in succession, without being preceded by any severe 
manifestation of the disease. Oftentimes the subacute form exhibits itself, 
either preceded or not by acute attacks, as well as interrupted in its suc- 
cessive occurrence by the more severe outbreaks. 

Its Distinction from other Grades and Forms. — In subacute attacks 
usually fewer joints are involved and are less severely affected. It is 
frequently stated that in this form the articular disease is not symmetrical, 
but as the joint involvement is so frequently non-symmetrical in the acute 
attack, this phenomenon is not a very characteristic or distinguishing 
feature between the two. On the other hand, the subacute form is not 
rarely seen assuming a symmetrical localization. 

The smaller joints do not seem to be more frequently or more exclu- 
sively affected than the larger ones ; usually fewer joints become involved, 
and a joint once affected generally remains so during the attack. The 
complete subsidence of the diseased condition in a joint and the so-called 
metastases to other joints are less marked. The pains are less acute, 
redness is rare or seen only in slight degree, but the effusions within the 
joint, when these occur, do not usually reach a large amount, are slowly 
developed, indolent in character, and not subject to rapid change. 

The tissues around and in the neighborhood of the articulations in- 
volved are very constantly affected, but exhibit the same tendency to in- 
dolence and to a low type of activity, and, in the more marked cases, while 
showing considerable swelling, that condition is not of firm character, and 
on subsidence leaves the structures less altered, anatomically at least, as 
judged by their external appearances, than is sometimes witnessed even 
after prolonged severe acute attacks, although the functions of these parts 
may remain for a considerable period much hindered. A resolution of 
this low grade of inflammation cannot be said to take place, at least in the 
ordinary sense of this word, so slow is the cessation of the active phe- 
nomena ; it seems to fade away and there is no point of time at which it 
can be said to be now here and then gone. It happens, perhaps not 
rarely, in some purely monarticular cases of this form of the malady, that, 



DESCRIPTION AND COURSE OF THE DISEASE. 81 

from bad treatment or want of care, the joint disease is unduly and in- 
definitely prolonged, and the results and the consecutive lesions become 
strongly pronounced ; from a misapprehension of the nature of the 
disease and from fixation of the involved joint by too strict care and 
avoidance of movements, false anchylosis from both peri- and intra-artieular 
changes of structure may be produced. 

The cardiac and other visceral complications are much more rare, less 
severe, and when they do occur are of shorter duration and apparently 
leave behind less permanent alteration. On the other hand, they are 
sometimes very marked. On this fact a strong point of alliance to the 
common form of acute rheumatism rests, and by it the differentiation of 
the subacute disease from chronic rheumatism, and especially from other 
so-called rheumatic joint affections having a grade or type more closely 
approaching to it, is frequently to be made. Severe visceral complications 
in subacute cases are witnessed, resulting disastrously or leaving behind 
them organic changes, especially of the heart, which permanently disable 
the patient and finally end fatally. 

Patients throughout an attack of subacute rheumatism in its usual 
form rarely exhibit the profound ansemia of acute attacks. However, not 
a few of the cases, perhaps rendered susceptible by this state, are already 
anaemic ; their mode of life, occupation, and their general nutrition may 
be productive of an anaemia, which is so constantly the resultant of the 
rheumatic disease. Not infrequently, the succession of the subacute 
attack to the acute disease or the frequent repetition of attacks render the 
patient more or less permanently anaemic ; to this may be added the effects 
of pre-existing cardiac or other visceral disease, owing to the same cause. 

The frequency of this form of the disease as compared to the acute 
attacks or to chronic rheumatism is a difficult question for determination. 
From its comparative slight severity it necessarily less frequently comes to 
observation, especially in hospitals, from whence alone accurate statistics 
can be obtained. My own impression, taken both from public service 
and from private sources, is that it is of exceedingly common occurrence. 

Subacute rheumatism is, therefore, from its frequency, from its train 
of symptoms, a well-merited name, and one from its useful application 
well deserving of retention as a distinctive form of the disease — a form of 
less severity, one differing from chronic rheumatism and one especially 
important to separate from non-allied joint affections owning a different 
pathological state, but which it sometimes closely resembles. 



CHAPTER YI. 

CONSIDERATIONS OF THE INDIVIDUAL SYMPTOMS OF ACUTE KHMCr- 
MATISM AND THEIR PECULIARITIES. 

Of the Fever : Chill ; Temperature Curve ; Modifications from Complications. 

It is necessary to speak more in detail, than is possible in giving a gen- 
eral account of acute rheumatism, of some of the characteristic phenom- 
ena, as well as of more rare symptoms, which attend its course. We 
shall speak first of the onset, the course and the decline of the fever, as 
shown by the thermometer, and of some of the alterations of function 
which attend and are dependent on the febrile state. 



Of the Fever. 

The discussion of acute rheumatism should properly be opened by the 
-consideration of its febrile phenomena. "While we do not look upon the 
disease as consisting simply of fever changes — the conception which oc- 
cupies us so largely with the other pyrexiae — yet most truly acute rheu- 
matism is not merely an articular inflammation. The severity and danger 
— at least the immediate dangers — arise, not from the local phenomena, 
but from the general febrile conditions. 

Acute rheumatism is never truly apyretic. In mild cases, such as have 
been spoken of as subacute, the fever may be so slight in degree as to be- 
come quite an insignificant phenomenon of the disease, or in fact be undis- 
coverable, except by careful search and pretty continuous thermometric 
observations. Although thus in a very numerous class of cases the fever 
is so slight, and though, too, in another class of cases the suffering from 
the articular pain is so much greater than the discomfort produced by the 
fever alone, still we must regard the pyrexia as the leading symptom, and 
the one which deserves our highest consideration. 

It is commonly said that the degree of fever-heat attained in rheuma- 
tism is proportionate to the number of joints subjected to inflammation, 



INDIVIDUAL SYMPTOMS OF ACUTE RHEUMATISM. 83 

yet this observation cannot be regarded as having any great value in 
either a diagnostic or a prognostic point of view ; nor yet can we regard 
any given case as mild, even if few joints be affected, if the range of tem- 
perature is greatly extended. 

The observation that the febrile movement runs no given course, and 
that at any period of the disease the patient is liable, with or without the 
involvement of new articulations, to sudden and dangerous exacerbations 
of body heat, is one of much greater value and significance and one that 
cannot be too constantly held in mind. 

Chill. — A chill is a very common though by no means constant symp- 
tom at the beginning of an attack of acute rheumatism. My own obser- 
vation is that the cases are very rare in which, as an initial phenomenon, a 
sense of coldness is entirely absent. In this matter we are wholly de- 
pendent on the account furnished by patients themselves ; some would 
describe a sense of coldness as a chill ; others, non-observant of themselves, 
forget their feelings ; while others would not mention a chill as among 
the symptoms, unless they fairly shook and their teeth chattered. Un- 
questionably a chill of this latter character is a rare symptom in rheuma- 
tism, while I claim that a sense of coldness, whether due to " chill," 
proper or to a draught of cold air, is almost never absent. Perhaps the 
only cases in which severe chills occur are those in which the patient has 
been subjected to a thorough and prolonged wetting ; these are the in- 
stances, however, which, owing to the precautions usually taken, are not 
followed by rheumatic attacks. 

The chilly sensations are soon succeeded by a feeling of warmth, and 
fever develops by night or at latest on the following day. Usually it 
rapidly rises to a considerable height, often attaining the highest point 
exhibited during the attack. As measured by the thermometer the tem- 
perature will be found between 102° and 103° F. In very many cases, 
however, the thermometer on the second or third night may be found 
registering even a degree higher, without the general condition or ap- 
pearance of the patient showing any more marked fever- symptoms than 
on the earlier day. The degree of fever is greatly modified by the care 
and surroundings of the patient. Probably nothing tends to keep the 
fever at a low grade more fully than complete rest in the initial stage of 
the disease. Every one familiar with hospital patients has noticed the 
high, often excessive temperature which they exhibit on admission to the 
ward. A thermometric observation taken of such cases within a short time 



S4 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

after coming to the hospital will show a higher range than at any subse- 
quent period of the attack, although the disease is evidently in its com- 
mencement, and later numerous joints become affected. This excessive 
temperature is evidently due in these cases to the exertion and pain which 
the patients suffer in removal from their home. It is undoubtedly a misfor- 
tune attended with subsequent evil. The high degree of heat is ac- 
companied with quickened respiration and a rapid pulse, and under these 
circumstances the removal. of the patient may lay the foundation for a 
damaged heart-valve. This suggestion is, I think, in accordance with the 
fact that rheumatic valvular disease is more common among the lower 
classes — such as would be likely to seek hospital treatment — than among 
the richer class of patients. Of course this condition cannot be accounted 
for solely by this difference in circumstances. 

Temperature Curve. — The temperature curve, although not exhibiting 
any regular evolutions or cycles in its range, may nevertheless be said to 
have a regular type, notwithstanding this regularity cannot be predicted in 
any case. It seldom happens that the actual beginning of the disease is 
under observation, but it may be fairly concluded, from the statements of 
patients, that the fever does not suddenly rise to an extreme height. 
This statement is, I think, to be modified, as already said, in those cases 
which do not receive proper care at the beginning. The height of the 
temperature is usually attained within the first four days ; in many cases, 
perhaps the majority, a more or less steady* decline is seen ; in other 
cases, the most severe ones, the temperature, after attaining a high point, 
remains steady at or about this point during two, three, or four days be- 
fore the gradual decline commences. 

During the declining stage the temperature exhibits in nearly every 
case exacerbations of more or less marked character. These elevations are 
found not only in cases where complications occur — as well as in those 
cases, which will be spoken of later, of hyperpyrexia— but in regular 
attacks of acute rheumatism. These exacerbations usually announce the 
involvement of new joints or the renewal of inflammation in articulations 
previously affected ; sometimes the temperature rises without our being 
able to point out the direct cause. 

In some of these instances I have thought it was due to changes in the 
weather, and the rise of temperature was certainly simultaneous in a 
number of cases with the occurrence of a rapid alteration in the baro- 
metric pressure, usually its diminution as seen preceding a storm ; in other 



INDIVIDUAL SYMPTOMS OF ACUTE RHEUMATISM. 80 

cases I have thought it due to attempts at exertion, which have caused re- 
newal of pain and discomfort to the patient. 

The number of days occupied by the declining temperature to reach a 
normal level varies very greatly, and the variations in the length of time 
cannot satisfactorily be accounted for by the apparent severity of the 
initial articular inflammation. In many cases, showing in the early stage 
an involvement of several even large joints, and in which the temperature 
within the first three days shows 104° F. — and this is especially true of 
hospital cases— the decline may be completed within a week or ten days, 
and be of steady and rapid character. 

In other cases even when the early rise of temperature is less, although 
quite as many joints are involved, the normal temperature is not attained 
until after the end of the second or even of the third week. However, it 
is only in exceptional cases of simple acute rheumatism, without reference 
to their severity, in which the nursing is good and the surroundings 
favorable, that defervescence is not completed by the end of the third 
week. And if cases last longer than this, apart from complications, the 
protracted period is due rather to constitutional causes, or some pre-exist- 
ing organic lesion, than to the rheumatism. 

In endeavoring to arrive at a conclusion as to the duration of acute 
rheumatism, many facts must be borne in mind. In the first place, the 
differences between observations in private practice and hospital statistics 
must be considered. Again, authors take a- different standard in de- 
termining the termination of the case ; some speak of the termination 
of the fever, some of the subsidence of the articular pains, and others of 
the restoration to mobility with comfort of the painful joints. Hospital 
statistics probably tend at the present time to shorten the apparent dura- 
tion of the attack ; in the first place, by not counting all of the days of 
illness prior to admission, and secondly, the patients are often discharged 
before complete restoration. In private, especially ainong the lower 
classes, the surroundings and the nursing naturally tend to increase the 
fever and prolong its continuance. While a mean between these two 
classes would probably give a correct idea of the duration of the disease, 
the statistics of private work are so scanty and too often so defective that 
reliable conclusions are not obtainable. 

Here, however, I am speaking of the decline and termination of the 
fever, and I think the statement is correct as above made, that in un- 
complicated cases, no matter how great their severity, defervescence takes 



86 

place by the end of the third week. It is probable that this statement will 
have to be soon modified, even if the time has not already arrived, and the 
febrile duration of the disease under more recent methods of treatment 
will be considered as capable of very great abbreviation. But this ques- 
tion will be alluded to further in the chapters on the duration of the 
disease and also under treatment. 

Wunderlich divides the range of temperature in acute rheumatism into 
three divisions. 1, the ascent or pyrogenetic stage ; 2, the height of the 
fever, and 3, the period of descending temperature. Of the first stage he 
says that the rise is never sudden, as is common for example in the acute 
exanthemata, although exceptional cases do occur where 104° F., or even 
more, is reached as early as the second to the fourth day. Of the height 
of the fever, many cases, he says, present a solitary peak as a maximum, 
and this generally occurs between the fifth and ninth days of the disease, 
though it may occur even earlier, or at a later period in some cases. 
"Very commonly, however, the summit extends itself into an actual 
fastigium. But this, in the majority of cases, is very brief in comparison 
with the whole duration of the disease, and is still shorter when very 
high temperatures are reached, though the case in itself may not be very 

severe It is only in very exceptional and in other respects 

severe cases that temperatures of 104° J?. (40° C.) or* more are reached or 
exceeded on three successive days." 

"The descending period shows a varied type according to the form 
assumed by the decrease and the suddenness with which it occurs." 
In the favorable cases the descent is quick and generally zig-zag, and 
perhaps without any evening rise. More commonly the decrease of 
temperature is protracted with, for several days, a tolerably stationary 
daily average rise and fall. This may take from ten to twenty days to 
reach the normal level. Even after this point is reached, or even a sub- 
normal level and" convalescence has set in, fluctuations of temperature, 
usually of slight degree, are not infrequent. Wunderlich further says : 
" After all, the fever in these cases of acute rheumatism is only of moderate 
or at the most medium severity. Apart from its brief acme it remains at 
heights which only exceptionally exceed the bounds of moderate fever." 

Modifications from Complications. — The visceral complications in many 
cases supervene without influencing the degree of bodily heat ; when, 
however, a rise of temperature occurs with or precedes the commencement 
of a complication, the rise is usually not very great. Occasionally a well- 



INDIVIDUAL SYMPTOMS OF ACUTE RHEUMATISM. 87 

marked chill ushers in the beginning of a complication, and this comes 
without additional exposure. The exceptions to this rule are pneumonic 
and meningeal inflammation, and are pretty much in accordance with what 
would be expected from the nature of the complication. Meningitis and 
pneumonia occurring alone give rise to a high temperature, while endo- 
carditis, pericarditis, and pleurisy may and do often occur latently or at 
least unattended with fever of marked character when these diseases are 
not complications of an acute rheumatic attack. The temperature subse- 
quently to the occurrence of a complication is modified in accordance with 
the temperature rule which exists for the intercurrent disease, and in this 
manner the maintenance of a febrile condition may be seen some time after 
the polyarthritic inflammation has subsided. 



CHAPTEE VH. 

CONSIDERATIONS OF THE INDIVIDUAL SYMPTOMS OF ACUTE RHEUMA- 
TISM AND THEIR PECULIARITIES.— Continued. 

Of the Joints : Development of the Articular Phenomena ; Reasons for the Involve- 
ment ; Attitude and Position of the Patient and of the Joints ; Cause, Seat, and 
Character of the Pain ; Redness ; Swelling- ; Subsidence of Inflammation ; Tem- 
perature of the Joints ; Comparison with Gout ; Numerical Frequency in the 
Different Joints ; Relation to Cardiac and other Complications ; Duration ; 
Metastasis. 

Of the Joints. 

After the pain commences in the joints, redness, swelling, and de- 
formity are rarely absent in marked cases. In the very earliest stages we 
may find a patient complaining of severe pain without these appearances 
being present, but very shortly some one of them will develop. 

Usually one joint is affected first, but this precedence is of brief dura- 
tion, other joints being rapidly involved in succession. It is commonly 
said that the larger joints, and especially the knees, are the first to be at- 
tacked, but I think this statement requires modification. 

Development of the Articular Phenomena. — While it is unquestionably 
true that in rheumatism, as compared with gout, the larger articulations are 
more apt to suffer or to be affected first than the smaller ones, I think that 
the more correct statement is that in rheumatism the joints most exposed, 
or perhaps most used, are the ones most likely to suffer. Thus in the 
carrier or postman the knee is more likely to be affected than the elbow ; 
and in the housemaid or washerwoman the wrist, or perhaps even the 
finger-joint3, suffer more than the ankle ; or in the maid-of-all-work, who is 
frequently engaged in washing the front pavement or standing in a damp 
kitchen, the ankle and foot are most likely to inflame. Still the determina- 
ation of the question which joints are the most used is very difficult, 
and the degree of use made will vary with the individual, although 
engaged in the same occupation. 



INDIVIDUAL SYMPTOMS OF ACUTE RHEUMATISM. 89 

Reasons for the Involvement. — The number of joints affected varies 
greatly in different cases and also with the severity and duration of the 
attack. In severe cases the number of joints involved is usually large, 
and so too if the febrile movement is of long duration. Although at first 
but one or two articulations are inflamed, other joints become affected 
during the prolonged course. However, a familiarity with a large number 
of cases will show every variety of character as to the number of joints 
originally inflamed, the number subsequently involved, and also the re- 
newal of inflammation in joints previously affected. 

Attitude and Position of the Patient and of the Joints. — The attitude 
assumed by rheumatic patients and the position in which they seek to 
place their limbs is a matter of some interest, often in a diagnostic point 
of view, and varies according to the generalization or localization of the 
affection, according to the stage of inflammation, and also to the presence 
or absence of effusions into the articulations. The position both of the 
patient and of the joints is modified greatly by the freedom or involvement 
of the muscular tissues. 

It may be said as a general rule that in the early stage, as soon as the 
pain becomes severe, the patient's whole attention is given to maintaining 
the inflamed joint in a state of immobility, regardless of position, and this 
is especially true if the muscles or their aponeuroses are affected. In a 
later stage, after effusion into the synovial sac has taken place, nearly every 
joint has a rule of its own for attaining the most comfortable position 
when in this condition ; it is such as will give the greatest relaxation to 
the ligaments and tendons surrounding the articulation. Thus for the 
upper extremity pronation, semi-flexion, and the hand flat on the bed will 
be the most conducive to comfort, the fingers if involved also semi-flexed ; 
while for the lower extremities semi-flexion at the knee and slight abduc- 
tion will be the position the patient will seek to assume ; if all these joints 
are affected and intensely inflamed, immobility is all that the patient 
will ask for, and nothing will induce him to move until some degree of re- 
lief is attained ; in cases where the vertebral joints are attacked the patients 
lie rigidly on the bed, like a soldier at "present arms." 

Cause, Seat, and Character of the Pain.— The cause, the seat, and the 
character of the pain have always been matters of considerable discussion 
and about which opinions have differed very much. The older authors, 
who regarded the disease as a local matter and strictly inflammatory in its 
character, contented themselves by simply pointing to the inflammation. 



90 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

In later times, as new opinions arose as to the cause and seat of the 
rheumatic disease, the question came up whether the pain was intra-articu- 
lar, peri-articular, or due to changes involving the nerve-trunks and their 
distribution around the articulation. These questions are obviously very 
difficult of settlement and are of the nature to test our powers of observa- 
tion to the utmost. Unquestionably the pain must be due to pressure 
made upon the nervous filaments, and the only point requiring discussion 
is the position of the filaments involved. Some would point solely to the 
nerve-filaments distributed to the synovial membrane, others to the peri- 
articular nerves, and others again to the nervous filaments distributed to 
the fibrous apparatus. 

It would seem that at times all of these situations were productive of 
the pain in a manner, so to speak, quite isolated, as well as perhaps others 
not directly specified; for example, the bursse and tendinous sheaths. 
Just as in some cases we find the morbid process localized or concentrated 
more particularly in one or the other of these parts, so in other cases they 
may all join when simultaneously affected in furnishing their quota of pain. 

It would be quite unprofitable to discuss the character of the pain, as 
to its burning, tearing, rending, or shooting nature. It may be generally 
stated that perhaps in the majority of cases the pain commences at night, 
before the swelling and redness make their appearance. It is apt to cease 
or lessen with the occurrence of the effusion, and does not reappear after 
the effusion has reached its maximum and begins to lessen. 

Redness. — The redness of the joint makes its appearance shortly after 
the advent of pain and usually before any marked degree of swelling, al- 
though occasionally the red color is not developed until a later period. 
The color varies considerably in its shade ; it is usually pretty evenly spread 
on the surface affected, over and around the joint. Sometimes it presents 
a bright red color like an erythematous blush. In other cases it is of a 
dusky hue ; and in still other cases it appears in narrow streaks or lines, 
often irregularly distributed, and under these circumstances the color is 
of a bright hue. In general it may be said the brighter the color the 
more superficial it is, while the dusky hues appear to be connected with 
changes in the deeper layers of the skin. It is said that the redness is less 
marked in rheumatism than in gout, although in some cases of rheumatism 
the color may be very pronounced ; and the engorged veins leading from 
the affected articulation are much less conspicuous in the former than in 
the latter disease. 



INDIVIDUAL SYMPTOMS OF ACUTE EHEUMATISM. 91 

The dusky red color occurs especially in those cases where the inflam- 
matory changes affect the peri-articular tissues, while the bright red color 
comes in connection with the large effusions within the capsular ligament ; 
the streaks and lines of redness call to mind the appearance of a lymphan- 
gitis, and in some cases it is very probable that they are due to involve- 
ment of the lymph-vessels. 

In all the forms of redness, and even when no very distinct coloration 
is visible, a white line or t:iche can be produced by drawing the finger 
over the skin covering the articulation ; it is, however, a torturing kind of 
experiment which serves no useful purpose. 

The color endures in proportion to the intensity and duration of the 
joint affection. It is usually visible only for a few days and, except in 
cases where it has been very intense, almost ecchymotic in character. It 
is not seen to persist after death. 

Swelling. — The swelling of the inflamed joints varies very greatly in 
amount, and unless influenced by pre-existing constitutional cachectic 
bodily conditions which tend to increase it and prolong its duration, it is 
more directly proportioned than either the pain or redness to the severity 
of the general symptoms. The seat of the swelling, as has been alluded 
to in discussing the cause and seat of the pain, may be due to effusion of 
serum taking place in either one of three positions or in all of them sim- 
ultaneously. In the vast majority of cases, if the swelling is at all con- 
spicuous, the cavity of the joint will be found to contain fluid, although 
sometimes very considerable enlargement may be present when but a 
small amount of fluid exists within the synovial cavity ; in this latter case 
the peri-articular connective tissue contains the bulk of the distending 
fluid. In certain unusual cases the bursse and the tendinous sheaths are 
found to present a striking amount of effusion, while but little forms in the 
joint cavity. 

Subsidence of Inflammation. — One of the most striking features of a 
rheumatic attack is the rapidity with which the evidences of an inflamma- 
tion disappear from within and around the joint. According to my own 
observation the development of the inflammation, attaining even a high 
degree, is more rapid than its complete subsidence and restoration to the 
normal. I think that the general impression conveyed by the statement 
of authors is the reverse of this ; and perhaps the misleading statement 
and the misapprehension of the facts are due as much to accepting the 
statement of patients as to errors of observation. Subjectively the joint 



92 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

is very bad from the moment the pain comes, and very well the moment it 
leaves, but objectively, the evidence of inflammation is pretty rapid in 
making its appearance originally or in renewing itself in a previously in- 
flamed joint, but is slow in disappearing. 

The sounds and the sensations, both of which may be conveyed to the 
observer or appreciated by the patient, occurring within the articulation 
are due to the alteration of its fluid contents. These phenomena have 
been compared to the sounds produced within the inflamed pericardium, 
but I think unjustly so, because, except in a few and quite exceptional 
cases, the products of inflammation within the joints are strictly fluid in 
character, while those in the pericardium which are productive of the Mo- 
tion sound are solid. The observations on the joint fremitus, as com- 
pared with the pericardial sounds, are of little value, are difficult to make, 
and simply result in torture to the patient. 

Temperature of the Joints. — The temperature of the joints, if inflamed 
in any marked degree, and in fact almost independently of their appear- 
ance as to redness, usually indicates from one to two degrees higher than 
the adjacent portions of the limb, and I believe the difference is less marked 
in rheumatism than in gout. This is probably in accordance with the gen- 
eral features of the two diseases ; in gout, with perhaps only a single joint 
affected, the degree of bodily heat is less, and therefore the difference be- 
tween the adjacent surface and the inflamed joint is much greater than in 
rheumatism, where the essential fever brings up the surface temperature 
nearer to the level of that of the affected articulation. 

Comparison with Gout. — I know of no observations showing a com- 
parative temperature of the joints in the two diseases, but I am inclined 
to think that in severely inflamed rheumatic joints the temperature ex- 
ceeds that of the gouty joint, although perhaps the gouty toe, which is 
always very painful, exhibits uniformly a higher temperature than the 
average taken of all cases of rheumatism measured on the surface of the 
joints. The joints in the two diseases present very striking differences, 
both during the continuance of the attack and on its decline. The gouty 
joint is smooth and shining and the skin over it appears stretched and 
pits on pressure ; subsequently the cuticle desquamates. In rheumatism 
the swelling is never sufficient or of such a character as to render the 
skin tense ; pitting on pressure may, however, be observed, though not 
commonly, and local desquamation does not come after a rheumatic 
attack. 



INDIVIDUAL SYMPTOMS OF ACUTE RHEUMATISM. 93 

Numerical Frequency in the Different Joints. — As already staled, cer- 
tain joints are more likely to be affected than others, and the true reason 
of this difference has also been given. It is of interest to state the nu- 
merical preponderance which one joint has over another, although in 
naming the order in which they are more liable to be attacked, it is in- 
correct to convey the notion of the regular evolution of the joint affection ; 
it is simply a statistical statement. That given by Monneret, and quite 
generally quoted, is that the right side of the body has a preponderance, 
and of the joints, 1, the knee ; 2, wrist ; 3, ankle, and then the shoulder, 
elbow, and hip ; the fingers more commonly than the toes and some fin- 
gers more frequently than others. It will be found that all joints are 
liable to involvement, not even the articulations of the ribs and the jaw 
escape, and that the synchondroses are sometimes inflamed. 

The number of joints affected in any case may be few or many, and it 
is usual for a considerable number to be involved in all protracted attacks. 
In some cases the disease invades only the large joints, but in much rarer 
instances only the small joints, with perhaps one, or at most two of the 
large ones, usually of the upper extremity, suffer. There does not seem to 
be any rule of relationship between cases with few or with many joints 
affected and the involvement of the internal viscera in the rheumatic dis- 
ease. 

Relation to Cardiac and other Complications. — In some cases, even pro- 
tracted ones, and with nearly all the joints suffering, the heart escapes, 
while in others, mild as to general symptoms, with only few inflamed 
joints and short in duration, the cardiac complication is serious and may 
become permanent. In cases of mild character like the latter, cerebral or 
other nervous complications or sudden hyperpyrexia may develop all out 
of proportion to the apparent severity of the rheumatic disease and even 
become fatal in their consequences. It has been thought that when only 
a few joints are affected the cases showed greater stubbornness, but this 
rule is certainly not of universal application. 

Duration. — The duration of the acute period of the joint affection is 
not precise — it is difficult to arrive at a limitation of what is meant by 
acuteness, but in general it may be stated that the maximum is reached 
and passed for any given joint in from three to seven days, and that after 
this time subsidence of the phenomena takes place. But for a long time 
subsequently pain and swelling may remain, though the redness be gone, 
and stiffness frequently may last much longer. 



94 



AND ALLIED DISORDERS. 



Metastasis. — The question of metastasis is one which in this disease, as 
■well as in various others, occupied a large space in the discussions of an- 
cient medicine, and does still linger in our phraseology if not in our 
thought. The transference, or what is apparently such, of the inflamma- 
tion from one joint to another is not truly a metastasis ; in fact, metastasis, 
except to a limited extent acting in the case of tumor-growths, is not be- 
lieved to exist in reality. Theoretically no such thing can exist in such a 
disease as rheumatism, and clinically the facts are not forthcoming in 
support of it. The description of the sudden subsidence of the inflamma- 
tion in an articulation and its immediate appearance at another point has 
been made very picturesque, but the reality is quite different from the 
picture. The inflammation does not by any means subside so quickly as 
described, and if the subsidence is at all rapid, in the majority of cases 
the patient is well and no more joints become affected. And when a 
number of articulations are involved in succession, the new inflammation 
commences before the old ones disappear. 

The metastasis from the joints to the viscera, especially the heart, af- 
forded the older authors more plausible grounds of belief in this theory 
than the external manifestations. The endocardial involvement, and not 
infrequently the pericardial also, as well as others, come quietly, unat- 
tended with symptoms until quite advanced in their morbid changes, so 
that the period of cardiac symptoms not infrequently becomes coincident 
with the subsidence of the articular disease. Hence, I say, there was more 
justification in the apparent fact of metastasis to the internal viscera than 
from joint to joint. The older physicians depended on the symptoms for 
diagnosis of cardiac disease, while we recognize its occurrence in advance 
of symptoms by its physical signs. 

But neither in the one case nor the other is there ground for belief in 
any metastatic relationship between the manifestation of disease in one 
place and the other, neither internally nor externally. However much we 
may differ as to the essential cause of the rheumatic phenomena, all are 
agreed that the cause is a general one and that the change is a blood al- 
teration ; that the manifestations seen first at one point and then at an- 
other are exacerbations in a disease which has a remittent cause, and not 
transference of a morbid material from, one place to another. 



CHAPTER Till. 

CONDITION OF THE SKIN AND ITS FUNCTIONS. 

Excess of Function— Sweating and its Significance : Its Frequency ; Its Characteris- 
tics ; The Difference of the Sweats — The Eruptions : Sudamina ; Urticaria ; 
Medicinal Eruptions ; Hemorrhagic Eruptions ; Eheumatic Purpura ; Hemophilia 
or Scurvy ; Embolic Purpura. 

The skin in the earliest stages of the disease is hot and dry, and while 
the fever is developing, presents no peculiarities other than those incident 
to the conditions found in any continued fever. Very soon after the full 
establishment of the attack and the development of the articular inflam- 
mation, the skin becomes moist, although it still conveys a sense of heat 
to the hand. But, owing to the presence of the perspiration, the skin never 
gives a feeling of pungent heat. In fact, the presence of the watery secre- 
tion and its evaporation from the exposed parts of the body often gives 
to these a sense of coldness while the concealed portions of the body, al- 
though covered with moisture, are felt to be distinctly hot. The heat, as 
felt on the general surface of the body, is, of course, of less degree than 
that of the reddened and tumefied joints. 

Excess of Function. 

Profuse perspiration is one of the most constant of the phenomena of 
acute rheumatism, and it would seem, as a general rule, that the more 
marked the fever and the more severe the case, tile greater is the tendency 
to sweat. Very often the perspiration, at least in copious amounts, is only 
partial, and while the brow, the chest, and the shoulders are covered with 
beads of sweat, the lower portion of the trunk and the extremities are 
found dry, or at least only slightly moist. In other cases the portions of 
the body exhibiting profuse perspiration may be the reverse of the above, 
or the whole body may be equally bathed in sweat. It is rare, except to- 
ward the termination of the attack, to find all parts of the body dry. 



96 RHEUMATISM, GOUT, AXD ALLIED DISORDERS. 

Sweating and Its Significance. 

The perspiration, a symptom almost as constant as the articular disease 
itself, lias been regarded (and is yet to a certain extent) as a phenomenon 
in the disease of very varying significance. Formerly this symptom was 
looked upon not only as characteristic, but, says Aitken, in 1866, as " na- 
ture's cure for the disease. It may be 'wasting and enfeebling,' as exces- 
sive perspiration always is, but it is highly sanative ; and if it does not 
occur, the pains are always more excessive and the constitutional symp- 
toms become more severe if the perspiration should unexpectedly cease. 
The materies morbi is obviously removed by the sweating, and the natu- 
ral cure of the disease is effected by these profuse sour-smelling perspira- 
tions. Those perspirations are only useless when they are not of this 
characteristic sour description. They are then emphatically ' useless, 
wasting, and enfeebling.' and ou^ht to be arrested." All those who have 
held views similar to the above insist very strenuously on the markedly 
acid condition of the skin secretion, and it is probable, although observa- 
tions are not at hand to prove the question conclusively, that while as a 
general rule the sweat in rheumatism is in many cases highly acid, yet it 
occurs not infrequently that the profuse secretion, while acid, is not more 
highly so than can be found in other morbid conditions and even in those 
of health. The striking peculiarity of the sweat is its peculiar, disagree- 
able odor, described as sour, and which may be said to be eminently char- 
acteristic of the disease. 

Its Frequency. — Todd and Fuller, who held most strongly the acid 
theory of rheumatism, taught the efficacy of the secretion in removing the 
poison from the blood, and pointed out that the more regular the perspi- 
ration and the more abundant it was in quantity, the more rapid was the 
recovery. The later opinions held in regard to this symptom are that 
while the condition may be looked upon as in some respects an essential 
part of the disease, or at least in most cases, that its occurrence exercises 
neither a favorable nor an unfavorable influence. It is certain that the 
sweating of rheumatism cannot be regarded as a critical sweat, such as 
occurs in relapsing fever, pneumonia, and other acute febrile diseases. 
Neither is the acid sweating debilitating, as are the sweats of phthisis. 

It is really a matter of great difficulty, in the face of such diametrically 
opposite views to determine which opinion is correct, and it is probable 
that the truth lies between the two. Perhaps it is true, as the older 



CONDITION OF THE SKIN AND ITS FUNCTIONS. 97 

authors held, that the excessive sweat-secretion is really sanative, hut 
more than likely not for the reasons which they thought. The old belief 
that it is an elimination of the materies morbi seems to rest on very 
slander ground ; no one seems to have been able to show conclusively that 
lactic acid exists in the skin secretions, or in fact in the blood. Any ob- 
servations to this effect depend mostly on the opinions of men biassed by 
certain humoral theories of rheumatism. 

We can readily believe, however, that although no poisonous material is 
gotten rid of by this means, nevertheless the sweating is distinctly bene- 
ficial. The cooling of the general surface which must be effected through 
this agency cannot fail to aid in averting one of the greatest dangers of the 
disease. We now depend, as one of our remedial agencies, on cold baths, 
packing, or sponging of the body to produce a like result. And this treat- 
ment becomes especially necessary in just those cases where the defective 
secretion of the skin is present, and which Fuller thought were unfavor- 
ably influenced by the absence of perspiration and the consequent reten- 
tion of the morbid product. 

The perspiration may be looked upon, in fact, if the expression may be 
allowed, as critical throughout the attack, for it is in those cases when the 
skin- secretion ceases, perhaps suddenly, which become characterized by 
the temperature rising to a dangerous level. 

Its Characteristics. — Dr. Maclagan has recently suggested that, as the 
acid sweats of acute rheumatism are altogether peculiar and constitute one 
of the ordinary characteristics of the disease, they are one of the common 
results of the action of the morbid poison. He scarcely believes in the 
lactic acid theory of the disease, although holding that lactic acid is pres- 
ent as the result of tissue metamorphosis, and that these metamorphoses 
are brought about by the presence of a morbid poison, in its nature mala- 
rial, whatever that may be. This author accounts for the sweating as an 
effect not due directly to the action of the morbid poison, but indirectly 
through the presence of the lactic acid produced by it in stimulating the 
skin to increased action. " There can be no reasonable doubt that the 
acid perspirations of acute rheumatism are due, not to an effort of nature to 
eliminate the rheumatic poison, but to the stimulant action on the skin of 
the excess of lactic acid formed during the increased metamorphosis of the 
tissues of the motor apparatus. These perspirations are to be regarded 
as neither prejudicial nor beneficial ; but as simply one of the necessary 
symptoms of the disease during whose course they occur." 



98 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The Difference of the Sweats. — It may be perhaps well to advert to two 
different kinds of, or perhaps conditions under which, perspiration takes 
place in rheumatism. What the older authors regarded as the beneficial 
excretion, and which is really characteristic of the disease, takes place in 
the earlier stages of the attack and is attended with heat of skin, a full 
and bounding pulse, and a loaded state of the urine, and the excretion 
has a peculiar odor. This is the characteristic, and, as we may say, useful 
sweat. 

Another form of sweating is that which occurs sometimes late in a 
protracted case, sometimes as the result of injudicious medication or 
nursing, or in debilitated or cachectic states of the constitution. This 
form is unquestionably harmful and its effect is enfeebling. The secretion 
possesses little of the characteristic odor, the skin is sodden, and the 
pulse soft, weak, and irritable. The skin is apt to be cold and the bodily 
temperature, as indicated by the thermometer, is little if any above the 
normal. This condition of the skin may be very properly repressed or 
corrected by medicinal agents. 

The Eruptions. 

Sudamina. — The skin, during its excessive activity, is, not infrequently, 
covered with sudamina. The presence of these miliary vesicles is cer- 
tainly neither more constant nor characteristic than their appearance in 
other continued fevers. It would seem as though some peculiar condi- 
tion of the skin was, in addition to the occurrence of sweating, a necessary 
precedent of their development. Eecently I saw a red-haired blonde 
woman covered from head to foot with thousands and thousands of 
sudamina, surrounded at their bases with a red area. The condition 
lasted four days and then faded away. It was not urticaria. Other skin 
eruptions are observed to occur at some period during the course of 
acute articular rheumatism. 

Urticaria. — The most common form is urticaria. The duration of this 
eruption is quite transient and, so far as my own experience goes, the sub- 
jective sensations connected with it are much less annoying than in cases 
of ordinary urticaria with equally severe local lesions. 

In one case, occurring in my ward at the Pennsylvania Hospital, I ob- 
served a skin lesion which at the first glance closely resembled urticaria, but 
differed from it in that within a few hours of its appearance a minute 



CONDITION OF THE SKIN AND ITS FUNCTIONS. 90 

vesicle developed in the centre of the reddened area or wheal ; this vesicle 
with equal rapidity became a pustule. The skin lesion, too, was attended 
with no itching and with only a very slight burning sensation. On the 
following day the color of the reddened area had almost completely faded, 
and its site was marked by the desiccating pustule, which in the course of 
a day or two longer disappeared. The patient suffered from a mild attack 
of acute rheumatism involving several joints ; perspiration was not a 
marked feature of the case ; the eruption appeared about the fourth day 
of the disease ; her skin was of a very delicate character. 

Medicinal Eruptions. — In describing skin eruptions caused by or ac- 
companying rheumatism, it should be borne in mind that several of the 
remedies in favorite use are capable of producing eruptions and that the 
medicinal diseases of the skin must be differentiated from those due to 
the rheumatic attack. 

Hemorrhagic and other Eruptions. — In several older authors, and in two 
recent; French theses, a hemorrhagic form of eruption has been pointed 
out. These have been variously spoken of as hemorrhagic rheumatism, 
rheumatic purpura, rheumatic haemophilia, scorbutic rheumatism, etc. 
While undoubtedly many of these observations are due to errors in diag- 
nosis, and while the vague pains and the oftentimes considerable febrile 
movement which may attend both scurvy and purpura as well as haemo- 
philia may lead to mistakes, I still think that in rare cases genuine acute 
rheumatism does exhibit patches on the skin closely resembling those of 
purpura, and which may be denominated very fairly hemorrhagic rheuma- 
tism, if any one wishes to use this name in describing an incident in the 
course of a general disease. It is perhaps as well used a term as epis- 
taxic typhoid fever would be for a case of this disease attended with hemor- 
rhage from the nose. 

Embolic Purpura. — I saw this phenomenon of hemorrhagic spots well 
displayed in a single case. The patient, a middle-aged man, had been 
exposed during sleep to a strong draught of air from an open car-window 
for at least two hours. Very quickly he suffered from laryngitis, with 
vague pains in the extremities, and almost immediately after this a con- 
siderable murmur was heard over the apex of the heart, systolic in time. 
Very shortly, owing to the complaints of the patient, an examination led 
to the discovery of numerous minute bright-red spots on the inner side 
of the arms and forearms. These spots varied in size from a pin's head to 
areas as large as a quarter of an inch in diameter. Their color quickly 



100 RHEUMATISM, GOUT, AXD ALLIED DISORDERS. 

became darker, but their further evolution was cut short by the death of 
the patieut within a day or two of the appearance of the lesion. The post- 
mortem examination showed a fringe of recent vegetation along the bor- 
ders of the mitral valve. This latter lesion was regarded as explanatory 
of the appearances of the skin, although it must be looked upon as a very 
rare result of endocardial inflammation. 

Such a lesion is doubtfully to be classed among the skin eruptions of 
acute rheumatism, while on the other hand it may help to prevent entire 
discredit being thrown upon this or other forms of a hemorrhagic appear- 
ance of the skin in this disease. 



CHAPTER IX. 

GENITOURINARY APPARATUS. 

Question of Rheumatic Localizations in the Kidneys — The Result of Contact with the 
Altered Urine — Comparison with Gout — Albumen, its Significance — Rayer's 
Rheumatic Nephritis — Intercurrence of Bright's Disease and Rheumatism — Lan- 
cereaux's Interstitial Nephritis— Embolism, or Secondary Albuminuria — The 
Bladder, Affection of its Muscular Tissue — Urethra, Ovaries, Uterus, etc. — Rheu- 
matic Orchitis. 

Question of Eheumatic Localization in the Kidneys. 

It is difficult te arrive at an accurate knowledge of the state of the 
kidney in the course of an acute rheumatic attack, or the effects which the 
rheumatic process has on these organs directly. That they are not af- 
fected or do not become the seat of localizations of the rheumatic inflam- 
mation similar to the heart, pleura, and the lung substance, seems to be 
pretty generally agreed to, and it is not likely, a priori, from the nature 
and structure of the kidney, that a further knowledge of the post-mortem 
appearances will show us that changes of a similar character do take 
place with any greater frequency than is now believed to be the case. 

The anatomical affiliations of the kidney are not with the fibrous tis- 
sues, which are generally the seat of the rheumatic process, but with the 
epithelial and mucous tissues. The large amount of fibrous or connective 
tissue in and around these glands is a congener of the mucous membrane 
and not of the general fibrous framework of the body ; hence the morbid 
affiliations are with the former rather than with the latter. 

On the other hand, however, if we are to judge of the condition of the 
integral parts of an organ by the state of its functional activity, or the 
changed character of its secretion, we can hardly escape the conclusion 
that the kidneys do suffer some alteration, as the result of the rheumatic 
process. This conclusion, however, does not necessarily carry with it the 
belief that a rheumatic localization takes place in the organ. in the same 
sense as in the pericardium. 



102 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The Result of Contact with the Altered Ukine. 

Then, too, we doubtless have secondary effects of the rheumatic process 
exhibited in the kidney more strikingly, and perhaps more commonly than 
the primary ones. Besides, an alteration of the normal secretion does not 
necessarily, especially in such an organ as the kidney, imply anatomical 
lesions of its tissue. A person deprived of water does not perspire, or the 
sweat is at most of a concentrated character without any diseased condition 
of the cutaneous glands. So, too, of the kidneys, their secretion may be 
changed solely from disturbances of the secondary processes of assimila- 
tion. But we can scarcely believe that disturbances of assimilation can be 
long maintained without an effect being produced on the kidney-tissues, 
and how long this disturbance may be continued and the epoch at which 
the effect passes over into and establishes a distinctive morbid condition 
are the points to be considered. 

COMPAKISON WITH GOUT. 

It is very certain that we do not find the kidneys affected by the rheu- 
matic process, as they are by gout, and this is true bdth as respects the 
frequency and the character of the renal changes. A few cases are on 
record which are quoted as instances of a rheumatic renal localization ; the 
metastasis of the inflammation to the kidney taking place on the subsidence 
of the articular symptoms. Formerly this phenomenon was believed to be 
common, much more so than at present, now that we distinguish the two 
classical arthrites with greater accuracy. 

Albumen, its Significance. 

Albumen undoubtedly does make its appearance in the urine in acute 
rheumatism, and this has been accepted by some writers as evidence of a 
rheumatic localization— as evidence that Bright's disease is a complication 
of the rheumatic process. The occurrence of albumen usually takes place, 
if at all, only at the height of the febrile movement, and lasts only for a 
day or two, or at most a few days. I do not conceive we are justified 
in regarding this occurrence as evidence of a Bright's disease nephritis. 
It is the same phenomenon and due to the same cause as albuminuria in 
many of the acute pyrexiae, and it subsides as with them, leaving behind no 



GENITOURINARY APPARATUS. 103 

after-effects that are appreciable on minute examination. In rheumatic 
fever, as in other fevers, it comes with the intensity of the febrile move- 
ment, and is caused by the tissue-changes in the renal epithelium, suffering 
from the same sort of parenchymatous inflammation or cloudy swelling 
which we see in the liver-cells and muscular tissue. 



Bayer's Rheumatic Nephritis. 

The form of rheumatic nephritis described by Eayer cannot be con- 
sidered as a localization of the rheumatic process, but is probably due to 
the embolic occlusion of the renal vessels. The other changes in the 
kidney productive of albuminuria belong to such changes as above de- 
scribed due to the febrile process, or to the effects of the treatment, espe- 
cially the cantharidal blistering, which, in the irritated kidney, produce 
results not likely to occur in a healthy person. 

Intercurrence of Bright's Disease and Rheumatism:. 

Some of the cases of albuminuria, in the course of acute rheumatism, 
are rather to be looked upon as instances of intercurrent attacks of ne- 
phritis, produced by the same accidental exposure that caused the rheuma- 
tism, and not as a localization of the rheumatic inflammation. Many more 
of the albuminuric cases are due to pre-existing Bright's disease, aggravated 
by the rheumatic fever. The intercurrence of rheumatism in the course of 
chronic albuminuria has not, however, been frequently met with. 

Lancereaux's Interstitial Nephritis. 

The form of Bright's disease to be looked for in rheumatism, or as a 
result of it, is the interstitial inflammation. This form is more closely 
allied by its genus with the rheumatic inflammation, but Lancereaux, who 
has studied this question closely, reports that its occurrence is very rare. 
This author has, however, found thickening of the walls of the renal ves- 
sels, especially the arteries, with narrowing of their calibre. This change 
of the vascular supply is connected so closely with disease of the cardiac , 
valvular apparatus, and also with contracting kidney, that it is difficult to 
disconnect the change of the arteries, and hence of the kidney, from the re- 
sults of the rheumatic process. It has been usual to think of the vascular 



1(U RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

change as the result of the chronic congestion of the kidney, produced by 
the defective heart-valve, but the reports of Lancereaux vrould seem to 
show that the vascular alteration arrives too early to be accounted for in 
this manner, and if the reports are confirmed it is probably due to vascu- 
lar changes, inflammatory in character, occurring in the vessels themselves 
at the same time as those we are familiar with in the heart- valves or aorta. 

Embolism, or Secondary Ai^tjmtnuria. 

The other form of albuminuria is the result of embolism. The epoch 
of its occurrence is usually late, and it is to be looked upon rather as a 
secondary or accidental phenomenon of the rheumatic process. Embolism 
cannot, however, be excluded from the list of complications of acute rheu- 
matism. Endocarditis may occur in any case, and the vegetations from 
the inflamed surface may find their way immediately into the renal vessels. 
The first attacks of endocarditis much less commonly furnish vegetations 
than do the valves already deformed and roughened by previous inflam- 
matory changes, and the kidneys are therefore much less likely to suffer em- 
bolism in first attacks of rheumatism than in subsequent ones. Pre-exist- 
ing or advanced valvular disease, therefore, may furnish the clue to the 
presence of albumen in the urine during the course of any acute rheumatic 
attack. 

The condition of the urine in these cases is peculiar, and furnishes 
pretty distinctive evidences of the cause of the albumen. An embolus, 
occluding one of the larger branches of the renal vessels very soon attests 
its presence by hematuria, smoky urine, albuminous to chemical tests, and 
showing under the microscope large numbers of blood-corpuscles, not in- 
frequently forming casts of the uriniferous tubules. The larger emboli 
are usually single, though more than one may successively present itself, 
and the amount of blood indicates proportionately the area of kidney in- 
volved. All the kidney-substance beyond the point of occlusion suffers 
from a blood-stasis, is congested, and the renal tubules of this area become 
filled with blood-corpuscles, which find their way into the mine. As soon 
as the congestion of the infarcted area passes away, that is, reaches the 
second stage of the progressive changes which tissues in this condition 
suffer, the blood ceases to appear in the urine. The albumen continues 
until a quiescent state of the involved kidney is reached. 

Many cases doubtless occur, and that too in primary attacks of acute 



GEOTTO-UKINAEY APPARATUS. 105 

rheumatism, where very minute emboli are present in the kidney without 
any evidence in the urine of this accident having occurred. The minute 
emboli are more likely to be found in cases of fresh endocarditis than large 
ones, and, if they become sufficiently numerous in the renal vessels, they 
may give rise to albumen in the urine without, however, the blood-cor- 
puscles, as above described, becoming abundant enough to attract atten- 
tion and lead us to suspect the cause of the abnormal condition of the 
fluid. 

The Bladder, Affection of its Muscular Tissue. 

Cystitis has been described by many authors as the result of acute 
rheumatism. By some it has been regarded as due to a metastasis or a 
true localization of the rheumatic process. By others it has been con- 
sidered the result of irritation communicated by the concentrated urine, 
perhaps unduly retained in the bladder. 

However unlikely we may regard the occurrence of a mucous mem- 
brane inflammation, it is certain that we see not very frequently a condi- 
tion of the bladder in acute rheumatism which can hardly be looked upon 
as other than a rheumatic condition of the muscular or fibrous walls of 
the viscus. We always see the patient disinclined to be disturbed to uri- 
nate, but we also see in a few cases exquisite pain produced during the 
act of emptying the bladder, or even when a catheter is used to remove 
its contents. The pain is located over the vesical region and is not devel- 
oped until its muscular walls are moving as they close on the decreasing 
amount of urine in its cavity ; the pain is not associated with rheumatism 
of the abdominal muscles. 

Urethra, Ovaries, Uterus, etc. 

Rheumatic localizations in other portions of the urinary and genital 
apparatus have a much less well-authenticated basis for belief. Various 
statements are made of the manifestations seen in the urethra, the ovaries, 
the uterus, and the testicles. 

Rheumatic Orchitis. 

Perhaps our knowledge of the condition of the testicle in acute 
rheumatism is more accurate than for the other organs, on account of the 
freer inspection to which this external organ is open. The testicle and 



106 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

its appendages, or their enveloping membranes, suffer from inflammatory 
attacks as the result of rheumatism. The inflammation may precede the 
outbreak of the articular symptoms or may occur during their course or 
at their termination. The condition is rapidly developed and attains its 
height with great promptness, just as we see in the migration of the in- 
flammation from one joint to another. The pain at the commencement is 
more intense than even in an orchitis, due to the usual pathological cause 
(though in other respects it resembles it), apparently because the effusion, 
coming more rapidly, puts the fibrous tunic more quickly on the stretch. 
The suffering usually is mitigated sooner than in the ordinary inflam- 
mation of this part, by the rheumatic process subsiding sooner, and relief 
comes often without the intervention of treatment. I have witnessed one 
such case in which the history was as above given, and it corresponds to 
records made by others. As this description is going to press I have 
heard a similar personal experience from a Mend who has been a frequent 
sufferer from rheumatism. 



CHAPTER X. 

THE URINE. 

Causes of its Alterations — Its Amount — Its Color — Its Reaction — Its Density — Urea- 
Uric Acid — Other Solid Ingredients — Albumen — Sugar — " Fibrinous Urine." 

The urine in acute rheumatism offers peculiarities which, while not 
sufficiently pronounced to be diagnostic, differ strikingly from those of 
other febrile maladies of equal grade ; the more severe the symptoms the 
more distinct are the peculiarities. 

Causes of its Alterations. 

The characteristic profuse sweating which attends the period of 
activity of the symptoms would lead us to anticipate changes in the 
urinary secretion, because, under all circumstances, we know that these 
two emunctories are complimentary, or supplementary, to each other. 
And we find, owing to an abundance of the skin secretion, a diminution 
in the amount of the daily excretion of urine. The change in quantity is 
apparently to a great degree proportionate to the amount of the sweating ; 
that it is directly so is impossible almost to determine, from the difficulties 
attending even an approximation of sweat in a person suffering from a 
grave disease. I know of no observation at all accurate on this question, 
although attempts have been made in this direction, by weighing the 
moistened or saturated linen of the patients and comparing the result 
with the varying daily amount of urine voided. 

Its Amount. 

However, the fact is well established, as is familiar to every one 
accustomed to examining the urine in acute rheumatism, that the daily 
amount is much reduced, and that the reduction is apparently greatest in 
those patients who sweat the most profusely. It is also known that this 



108 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

change in amount consists chiefly in a reduction of the amount of water, 
which, instead of passing by the kidneys, escapes by way of the sweat- 
glands. 

More important questions for solution than the mere quantity of the 
urine and the deficiency of the watery element are whether the solid in- 
gredients are altered, and whether this alteration is in any manner charac- 
teristic of the disease. In all febrile conditions certain changes, greater 
or less, are to be noted in the quality and character of the urinary salts, 
but in few if any of the continued fevers can the changes be spoken of 
as strictly characteristic, and certainly not diagnostic ones. While 
in many of the local diseases, not of a constitutional or a general sort, 
though attended with the general symptom of fever, many alterations of 
the urinary ingredients are well recognized and are of a diagnostic 
significance, these alterations may be found to consist of a reduction or 
absence, or of an increase of a normal urine salt, or, on the other hand, 
of the addition of a new ingredient to the urinary fluid. 

In taking account of the changes in the character and amount of the 
urinary salts, attention must always be paid to the effects produced by 
drugs, which act either by increasing the amount of fluid, by changing the 
chemical combination of certain ingredients, by lessening the acidity or 
changing it to alkalinity, or finally by the addition of new chemical constit- 
uents or coloring matters. In either of these various ways the characters 
of the urine in acute rheumatism may be altered beyond recognition, and 
this effect has doubtless in many cases caused great variations of opinions in 
respect to the characters of the urine in this disease. Eemembering these 
facts will help to reconcile the discordant observations which are on record. 

The following statement, taken mostly from original observations, sup- 
plemented by the work of others, will, I think, give a correct account of the 
general appearances of the urine, its chemical composition, and some of 
the peculiarities which it presents, as well as some to which the fluid is 
subject, under various modifying circumstances. 

The quantity of urine is usually very greatly diminished, but the 
amount of diminution changes from day to day, and is, as has been said, 
proportionated to the activity of the skin function. In judging of the 
daily quantity, as well as the diurnal variations, it is well to bear in 
mind the errors to which such observations are liable, owing to the pain- 
ful condition of the joints and the disinclination of the patient to be dis- 
turbed to attend to this necessity of nature. Patients, during the great 



THE UEINE. 109 

reduction in the urinary secretion, often attempt to retain the urine for a 
great length of time rather than move ; hence the secretion of to-day may 
not be voided until to-morrow, thus producing a large apparent diurnal 
variation of quantity. 

The acid, and therefore irritating, quality of the urine puts a certain 
degree of check on this retention, and generally, unless the pain in mov- 
ing is very extreme, the patient will choose the lesser of the two evils and 
void the urine to escape the vesical irritation. 

Another source of error, I know, sometimes enters into the calculation 
of the quantity, and is directly due to the voluntary efforts of the patient 
in delaying to empty the bladder. Urine retained in the bladder unques- 
tionably suffers a diminution in amount through the reabsorption of a 
part of its water, with the effect of producing a quantitative as well as a 
qualitative alteration in its composition. 

In attempting accurately to ascertain the diurnal variations, strict at- 
tention must be given to the frequency and the hour of the day the urine 
is passed. In ascertaining the amount of reduction during a rheumatic 
attack, a system of averages, with due attention to the degree of the febrile 
symptoms, will, on the whole, probably furnish the most accurate notion 
of this change. 

The record of measurement of the daily quantity may vary from nearly 
or quite normal to zero ; the normal quantity of urine may be nearly at- 
tained in cases where sweating is but slight, and also where the imbibition 
of water or medicated diluent drinks has been very great ; unless these 
two factors are conjoined the urinary secretion is much reduced ; one of 
my urine records shows that none was passed during a single period of 
twenty four hours, due partly to diminished secretion and partly to the 
voluntary effort of the patient to avoid movement. 

Manifestly the above observation is of no value in determining the 
quality of the secretion of urine in acute rheumatism ; it merely records 
the amount passed. There are records published, presumably free from 
this error, which show that between three ounces and three ounces and a 
half only have been passed during twenty-four hours, and this condition is 
almost to be regarded as one of anuria. A reduction below one-fifth or 
even one-fourth the normal amount is rarely observed. It is probable that 
the average of a large number of cases will show the daily quantity to be 
about one-half the normal. This group will include both moderate and 
very severe cases. 



110 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Its Colok. 

The urine in the active stage of acute rheumatism is always high 
colored, and it is usually of a deeper tint than in any other general febrile 
malady. The color of the urine is due to the increase of one or the other 
or all of the various pigments which are found in this fluid, and therefore 
the deeper tint observable in rheumatic attacks is of itself indicative of a 
change of composition of the secretion directly connected with morbid 
process. 

This augmentation of the coloring matter, always present in the dis- 
ease, influences the character of the urine by increasing its density ; for 
the coloring matter is one of the principal substances comprising the solid 
ingredients of the secretion during the duration of the attack. 

The urine, freshly passed, is, though highly colored, still clear and trans- 
parent, but very rapidly on cooling becomes clouded by the precipitation 
of a sediment, which more or less rapidly sinks to the lower part of the 
vessel ; sometimes, however, the urine, even freshly passed, is clouded. 
This is usually owing to its extreme concentration, rather than to the ab- 
solute increase of any one of its ingredients. 

The high color usually presented is yellowish red or reddish yellow, 
or sometimes red or pinkish ; this high color is lessened as soon as pre- 
cipitation commences. With the cooling of the urine, or in cases in 
which the urine is turbid when passed, the high color is never so striking 
in appearance. 

It will be found to happen very frequently that a urine, which when 
passed is high-colored, yellowish red or reddish yellow, and transparent, 
becomes soon turbid from precipitation, shows after the settling of the 
sediment a pale yellow or amber color, and is transparent ; the sediment 
in such cases is of a bright red color. 

In a few cases, a yellowish red urine after precipitation shows the su- 
pernatant clear, transparent fluid of a bright red color ; the precipitate 
usually is of a yellowish red color. 

These variations of color show a difference of behavior of the color- 
ing matter in relation to the urinary salts ; in one case the pigment ad- 
heres or combines with the uric acid or the urates and is carried to the 
bottom, while in the other instances the pigments show a greater degree 
of solubility. In some cases the variations must be accounted for by a 
difference in the amount of coloring matters present in the urine. 



THE URINE. Ill 

In the vast majority of the cases of acute rheumatism, the opacity and 
the precipitate produced in the urine is due to the presence of uric acid 
and urates. This acid and its salts are insoluble in cool urine, especially 
when abundant, and in some cases the concentration of the secretion alone 
is sufficient to cause turbidity and precipitation, independent of an abso- 
lute increase in the amount of these ingredients. 

In a few unusual — they might almost be called abnormal — cases the urine 
is turbid or opaque when passed, but the color is not of a deep tint. It is 
whitish, and in a few instances I have seen it sparkle. Heat does not dis- 
solve the precipitate, but an acid renders it clear. The urine in these 
cases is more abundant than is usual in the disease. The chemical and 
microscopic examination shows the presence of phosphates instead of uric 
acid and the urate, and that its reaction is neutral or alkaline. 

I have not seen the patients who have passed such urine, but have had 
the samples sent to me for examination, and therefore cannot speak from 
personal knowledge of any peculiarity of symptoms, if such were exhibited, 
occurring in connection with this very unusual condition of the secretion. 
Dr. Fuller speaks of two cases in which the urine showed peculiarities 
similar to these I have alluded to. In two cases under his care the urine 
" was abundant, pale, alkaline, and turbid, containing crystals of the am- 
monio-magnesian phosphate. In both instances the patients were weakly, 
and their perspiration was of a peculiarly acid nature." He adds that 
something of the same sort has been remarked by others. It is probable 
the urine pigments are deficient in such cases. 

The question of the nature and condition of the coloring matter is of 
nearly the same importance as its amount. The condition, or perhaps com- 
bination of the pigment in the urine of acute rheumatism, as we have al- 
ready seen, varies considerably from circumstances with which we are not 
acquainted. In the majority of cases the coloring matter is precipitated, 
at least a considerable part of it, along with the sediment which we know 
to consist of uric acid or urates. In other cases, on the contrary, after the 
precipitation of these salts the supernatant fluid is of a brighter, usually 
reddish color, than before the precipitation occurred. Evidently, there- 
fore, there are variations of the conditions under which the pigment ex- 
ists in the urine. This variation may be dependent on two causes : 1, a 
variation of its relations to the uric acid salts, or 2, a variation in the 
nature of the coloring matter itself. 

As a rule, we may say that the coloring matter attaches itself to the 



112 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

uric acid crystals and somewhat also, though to a less degree, to the 
urates. 

In respect to the nature of the coloring matter, it is unquestionably 
due to the presence of blood-pigments. The blood in rheumatism is, as 
we will point out later, subject to very rapid changes, especially a dim- 
inution of its red corpuscles, which are in part the carriers of the blood- 
pigment. Therefore, from the destruction of these corpuscles, the urine 
contains a larger amount of the coloring matter derived from this source. 
This alteration of the color of the urine may be spoken of as an increase 
of its normal color. 

There is another pigment, which is derived from the changed function 
of the liver or the chylo-poetic viscera. This pigment also makes its ap- 
pearance in the urine in other diseases than rheumatism, and also in 
health. It is therefore not an abnormal urine pigment although the result 
of abnormal causes, but is one of the special urinary pigments. It is 
called urobilin. 

Other pigments have been described in the urine during the acute 
stage of rheumatism, but their composition and source are but little un- 
derstood or entirely unknown. 

Its Reaction. 

The urine in acute rheumatism in the early stage and during the 
height of the paroxysm, and even later, has an acid reaction, unless af- 
fected by remedies, usually of an alkaline character, administered to com- 
bat the disease. 

The acidity is a very striking feature of the rheumatic patient's urine. 
The other peculiarities of the urine in this disease partake of the nature 
common, to a greater or less extent, with those of some other continued 
fevers, and are therefore to be accounted for partly by the, febrile process, 
apart from any peculiar pathological process due to the rheumatic affec- 
tion. Quite otherwise is it with the acidity. The acidity of the rheu- 
matic patient's urine is in excess of that found under circumstances of 
disease or health, beyond that which can be produced by the ingestion 
of foods or medicine and a condition hard to change or neutralize by the 
administration, except in large quantities, of drugs calculated to influence 
or produce an alkaline quality of this secretion. 

The more concentrated the mine, the more acid it is usually found. 



THE URINE. 113 

This rule is, however, subject to variation, as occasionally with a relatively 
free secretion from the kidney, or at least a larger measured quantity of 
urine passed, the fluid possesses a more strongly acid quality than when 
scanty. However, I do not think we are in possession of observations, made 
under proper conditions, to allow of our making a positive statement of this 
fact. So much of urine work is done in connection with medication, which 
necessarily alters the condition of the urine, and so few observations are 
published of the natural history of the disease unmodified by remedial 
agents ; occasionally, too, under the effects of drugs, a sudden diminution of 
both the quantity and the acidity results, that we are hardly prepared to 
say how much the acidity is due to concentration of the urine and how 
much is directly the result of a febrile process in increasing the absolute 
amount of acid-reacting material. 

Then, besides, our knowledge of which ingredient is the cause of the 
acidity is defective. Some hold that it is the normal urine products, pres- 
ent in increased amount as the result of febrile process, in which case the 
increased acidity must be, to a great degree, considered as but a part of 
the high concentration of the fluid ; while others consider the presence of 
a special acid (lactic acid) as the specific acidifying principle, in which case 
the heightened reaction is due to rheumatic process as such. But this 
particular acid has not been identified in the urine, at least in greater 
amount, if even at all, beyond that found in health, and therefore cannot 
be charged with producing this condition, or others which have been at- 
tributed to it. Perhaps, however, the change which is found occasionally 
to occur in a urine highly acid when passed to a condition of alkalinity 
may be accounted for by the disappearance of an evanescent acid like lactic. 

Its Density. 

The specific gravity of the urine varies very greatly, being influenced 
by the severity of the attack and showing a different grade at different pe- 
riods of the disease ; it is likewise altered as the result of treatment. Of 
course, the degree of concentration of the fluid exercises the greatest in- 
fluence, and in fact determines the specific density of it apart from the 
special influence of the rheumatic process. But it is nevertheless true 
that in acute rheumatism the specific gravity of the urine is increased. 
This is due, as will be shown later, to the increase of its solid contents 

and not merely the result of concentration. A verv simple experiment 
8 



114 RHEUMATISM, GOUT, AND ALLIE*D DISORDERS. 

will prove tliis fact ; if we collect the whole amount of urine passed during 
twenty-four hours and add to it sufficient water to raise the whole bulk to 
the average daily quantity in health, it will be found that the specific 
gravity exceeds the normal. 

I am not in possession of the facts of a sufficient number of such experi- 
ments to say how great is the average increase of the specific gravity. 

The specific gravity of the urine as passed shows variations within a 
very considerable range — a range considerably greater than that shown by 
urine in health and under circumstances in respect to the ingestion of 
food and drinks not likely to influence its specific density. The range in 
disease is influenced most markedly by the activity of the cutaneous secre- 
tion and to a less degree by other conditions. 

Its specific gravity, in any well-marked case of rheumatism, is very 
rarely found to be less than 1,017. It may, however, attain to 1,036. An 
average of a considerable number of cases gives the figures 1,026. It is 
useful, therefore, to speak of the usual range of the specific gravity as being 
between 1,020 and 1,030. 

The foregoing considerations of the urine of acute rheumatism show a 
considerable similarity, except in two points, to the conditions brought 
about by any febrile process ; the acidity and the greater concentration 
alone can be looked upon as strictly peculiar to rheumatism. 

It remains, therefore, to examine this secretion and to determine the 
amount of its several solid constituents to ascertain whether the rheumatic 
process influences their amount in a characteristic manner. As already 
mentioned, the solid ingredients are increased in amount. Which of 
them are affected, to what extent, and whether some of them or all, re- 
mains to be determined by quantitative analyses. 

Urea. 

In arriving at a determination of the amount of urea excreted daily in 
this disease, as compared with health, there are several very important cir- 
cumstances to be borne in mind. In health its amount is influenced by 
sex, a considerable preponderance occurring in men, by the nature and 
quantity of the food, by the amount of physical exercise and by the weight 
of the patient. Therefore in rheumatism the comparison must be made 
with a healthy person at rest and taking nourishment of the same charac- 
ter as the sick diet, in order that the estimation may be just and of value. 



THE URINE. 115 

During the acute stage the daily amount of urea excreted, after making 
due allowance for influencing circumstances, is increased. 

According to various analyses the mean average of the daily excretion 
in health is from 20 grammes (308 grs.) to 22 grammes (340 grs.). The 
maximum being about 35 grammes (540 grs.) and the minimum 15 
grammes (230 grs.). 

During the acute stage of rheumatism, attended with rapid pulse, fever, 
and sweating, the average daily excretion of urea will be found to corre- 
spond very closely to 30 grammes, or about 460 grs., the maximum reach- 
ing 50 grammes, or about 790 grs., and the minimum falling to 18 grammes, 
or about 280 grs. 

Dr. Stevenson, in the twelfth volume, third series, " Guy's Hospital Re- 
ports," gives figures which differ considerably from the above for the 
amount of urea, both in health and in disease. He states the maximum 
of health to be 479.95 grs. (31 grammes), the minimum 377.94 grs. (24 
grammes), and the mean 422.85 grs. (27 grammes). Of the seven cases of 
rheumatism, the urine of which he had analyzed, the maximum is 695.95 
grs. (45 grammes), the minimum 211.20 grs. (13J grammes), the mean is 
406.77 grs. (26 grammes). It would seem both from the clinical history 
and from the chemical analysis that the cases reported by Dr. Stevenson 
are hardly to be looked upon as fair examples of the condition of the 
urine in acute rheumatism. The minimum, as furnished by his figures, 
is lower in the diseased than the normal condition, and his figures are re- 
duced by the occurrence of several cases which excreted less urea during 
the active stage of the disease than during convalescence. This is a rela- 
tion which is the exact opposite of the conclusions which he draws in re- 
spect to these two stages of the disease from his own figures, and there- 
fore I do not think his results can be accepted as typical of the excretion 
of urea during the acute stage of the disease, or at all events his figures 
are misleading in expressing the true proportions. 

During convalescence, or at least after the subsidence of the fever, the 
daily excretion of urea is depressed below the normal. The degree of 
this depression is about equal to the degree of excess during the active 
stage. The average of a considerable number of cases taken from vari- 
ous sources shows a mean of 15.499 grammes (236.44 grs.). During this 
stage of the disease the urine becomes light-colored, increased in quan- 
tity above the normal, its specific gravity less than normal, and not infre- 
quently its reaction is alkaline. 



116 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Here again Dr. Stevenson's figures, taken from the source above 
quoted, show a mean average amount of 638.12 grs. (24 grammes) which, 
while it is below the mean average for health as shown by his figures, is 
considerably above the mean average as obtained from other sources. 



Uric Acid. 

All observers agree in pointing out the marked increase in uric acid 
during the acute stage of rheumatism. In fact, by most it is considered 
the agent which gives the urine in this disease its strongly acid quality. 
By some it has been held that the increase of uric acid is in inverse pro- 
portion to the amount of urea present during the febrile stage. It is con- 
sidered by these authors that the febrile process,, by preventing the trans- 
formation of the urea, increases the amount of uric acid. 

We shall find by our figures that this inverse ratio between the two is 
not shown, but that both of these urinary principles are augmented dur- 
ing the acute stage and both are likewise diminished and even depressed 
below the normal during convalescence. 

In health the daily excretion of uric acid is influenced very greatly by 
the character of the food, and when this is exclusively or largely of animal 
nature the amount of uric acid is increased. It is necessary, therefore, in 
examining the urine of rheumatic patients, to bear in mind the character 
of the diet with which they are supplied. 

Thus, in health, an exclusive diet of beef-tea will greatly augment both 
the urea and the uric acid excretion. 

We may accept as a standard of comparison that the daily amount of 
uric acid is 0.654 gramme. An average of a considerable number of 
cases (nearly the same cases as those used in obtaining the average for 
urea) shows that during the acute stage uric acid is increased to 1.294 
gramme. 

During convalescence, the uric acid is diminished to 0.384 gramme, 
nearly one-half less than the average in health. 

Other Solid Ingredients. 

It would seem, from the consideration of the scanty analyses of the 
urine of rheumatic patients, that the other urinary constituents, especially 
the phosphates and the sulphates, show a slight increase in amount, 



THE URINE. 117 

though to a much less degree than the urea and uric acid. This condi- 
tion is in marked contrast with the result of analysis of the urine of 
gouty patients, where the uric acid, especially in the early stage or before 
the beginning of the gouty paroxysm, is diminished or absent, while the 
phosphates are markedly increased. 

The conclusions which Dr. Stevenson has drawn from his examinations, 
in respect to the amount of the urinary salts, corresponds to the above 
statement. His attention, however, was principally devoted to an en- 
deavor to formulate a rule of prognosis from the relative amount of the 
urinary salts found in the urine. On this point he concludes as follows : 
"1. In acute rheumatism, when the excretion of solid materials in the 
urine is large, the patient makes, other things being equal, a rapid 
recovery ; on the other hand, in lingering cases the excretion of solids is 
usually small. 2. As in this disease the urine is invariably scanty in 
bulk, but (generally from this cause only) of high density, a useful guide 
to the progress of the case may probably be found by diluting the urine 
to the normal bulk, and then ascertaining its specific gravity. According 
as it is now of high or of low density will the progress of the disease 
probably be favorable or unfavorable." 

The only ingredients of the urine which do not show an increase 
are the chlorides, which follow the rule in respect to them which obtains 
in all other diseases of an inflammatory character. Their amount is 
actually diminished, though to a less degree than in some other inflamma- 
tory processes, for example, in pneumonia. Their amount of diminution 
always seems proportional to the amount of the inflammatory material, es- 
pecially of a solid character, which is thrown out, although the amount of 
the chlorides is influenced when the inflammatory material is entirely 
fluid. Perhaps the more strict statement of the relation between the 
chlorides in the urine and the character of the inflammatory material is 
not so much the difference between the solid and fluid character of the 
morbid material as between the absolute amount of the chlorides con- 
tained in it. Thus the croupous material filling the air-vesicles of the 
lung contains more of the chlorides than the fluid filling the pleural sac, 
therefore, in pneumonia the diminution of the chlorides in the urine is 
much greater than in pleurisy and very much greater than in rheu- 
matism. 



118 



ALBUMEN. 

As a rule, albumen is a rare constituent of the urine in acute rheu- 
matism or in any form of the disease. But nevertheless it does make its 
appearance occasionally. Its especial significance cannot be said to be 
very great and its detection does not give greater alarm than that fur- 
nished by the other more apparent symptoms of the disease present at 
the time when the albumen is detected in the urine. According to my 
own experience, albumen is much less commonly detected in the urine in 
acute rheumatism than in typhoid fever. The cause of its occurrence 
and its significance is about the same in the one disease as in the other. 
This is true at least so far as the anatomical changes in the kidney are 
concerned. In all febrile diseases we have changes taking place in the 
cells of the renal tubules — changes which may be briefly described as 
cloudy swelling — and which occasionally come to our observation during 
life by the appearance of albumen in the urine. 

The amount of albumen is scarcely more than a trace, and its occurrence 
is of short duration, cotemporaneous with the height of the disease. 

Albuminuria in acute rheumatism has been observed to result from 
what would be described, according to the older authors, as a metastasis 
of the rheumatic disease to the kidney. Of this we will speak further un- 
der the head of complications. 

Sugar. 

I know nothing of the occurrence of saccharine materials in the urine 
during the continuance or as a result of an attack of rheumatism ; neither 
have I been able to find any records of such a condition. 

Fibrinous Urine. 

A rare condition of the urine has been described under this head, but 
which probably should be spoken of under the head of albuminuria rather 
than as a separate condition. I have been able to find very few cases of 
it on record, and have seen but one myself. The urine in this case pre- 
sented no special differences from those usually described in the acute 
stage of rheumatism. It contained no albumen, or at least not that kind 
of albumen which responds to the test of heat and nitric acid. The 



THE UftlNE. 119 

whole bulk of the urine at the time of my examination of it presented a 
feebly clotted or jelly-like consistence. 

This condition seems to be similar to that spoken of by Senator and 
others. My examination of the specimen was but very imperfectly carried 
out, and I am able to give no further details in regard to it. I know of 
no better description than to speak of it as clotted urine, and that it re- 
minded me of the white of egg mingled with water. 



CHAPTER XL 

COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS. 

Their Importance in Rheumatism — The Point of View from which they are to be 
Regarded — The Order and Frequency of their Occurrence : Muscular ; Circula- 
tory ; Respiratory, Cere bro- Spinal, Digestive, and Urino-genital — Cardiac Lo- 
calizations : Our Knowledge of them ; Their Frequency ; Various Forms of Car- 
diac Lesions Collectively ; Their Relative Frequency and Combination. Time 
of their Occurrence and Concurrence ; Symptoms of Endocarditis ; Symptoms of 
Pericarditis — Rheumatic Localizations in the Vascular System. 

Their Importance in Rheumatism. 

Rheumatism is peculiarly liable to be attended with complications, prob- 
ably to a greater degree than any other disease, and these complications 
occupy a very considerable part of our attention, not alone from their 
frequency, but also from their severity, both immediately in the course 
of the attack and from the subsequent grave effects which they entail on 
the organism. 

It is a matter of some doubt in what manner these effects should be 
spoken of. Formerly they were considered as metastases of the rheumatic 
inflammation from the articulations to the internal viscera, but latterly it 
has been customary to describe them as complications. It is probable, 
however, that to look upon them as multiple localization of the same con- 
dition will afford us a more philosophical point of view of their nature 
and true relationships. In other words, the visceral, or extra- or ab- 
articular localizations are really integral parts of the disease, quite as 
much as the joint affection, and thus the rheumatic heart holds a different 
relation to this disease from what perforation of the intestine does to 
typhoid fever or pleurisy to relapsing fever ; the latter are truly compli- 
cations of those diseases. 



COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS. 121 

The Point of View fkom which they are to be Regarded. 

This view receives confirmation from the fact that extra-articular local- 
izations may occur prior to the development of the joint inflammation, 
and therefore it would be equally just in such cases to describe the artic- 
ular disease as a complication of rheumatic inflammation of the heart — 
manifestly a wrong judgment to make of the question. 

The Order and Frequency of Their Occurrence. 

Muscular. — The most frequent of the localizations of the rheumatic 
disease, and standing next in rank to the articular inflammation, are the 
phenomena developed in the muscular apparatus. So constant is the in- 
volvement of the muscles and their connections or appendages in the 
rheumatic process, during acute attacks, that I am inclined to place these 
organs in the same rank with the joints. The cases of acute rheumatism 
are indeed very rare in which the muscular tissues do not exhibit some 
one or other of the symptoms of the malady to a very considerable degree. 
The articular inflammation is, however, of so much more severe grade, 
and, from the nature of the parts involved, so much more painful, that 
the muscular disease falls into the background in our consideration of the 
rheumatic symptoms. 

The particular manifestations of muscular rheumatism, especially as 
seen when occurring apart from the articular disease, are very important 
as well as interesting, and later on special consideration will be devoted 
to them. 

Occurring in the course of rheumatic fever, when they are thus seen, 
they form so much a part of the general articular disease that it does not 
seem best to look upon them as a special complication or localization, as 
we are wont to do in respect to the visceral rheumatic manifestations. 
And then, too, their treatment as they occur in the course of acute rheu- 
matism, especially in the height of the attack, forms but a part of general 
treatment, quite unlike the indications when seen in subacute cases or 
when occurring alone. 

Circulatory. — Next in frequency, and of vastly greater significance and 
importance are the lesions of the circulatory apparatus. And here we 
enter on grounds which require a high order of skill on the part of the 
physician, not only to meet the requirements for their immediate recogni- 



122 EHEUMATISM, GOUT, AND ALLIED DISORDERS. 

tion and treatment during the course of the acute attacks, but also dur- 
ing the remainder of the patient's life to regulate the circulatory functions, 
which have become impaired through the effects of the rheumatic process. 

The parts to be considered under this head are three : First, the heart ; 
second, the vessels ; and third, the capillary network. The lesions and 
symptoms of this latter division appertain more properly to the tissues or 
organs in which the minute vessels find their distribution. 

Respiratory, Cerebrospinal, Digestive, and Urino-genital — The next in 
order to the cardiac lesions, and occupying a successively inferior impor- 
tance, come the localizations in the respiratory apparatus, the cerebrospi- 
nal, the digestive, the urinary, and finally the genital organs. 

Cardiac Localizations. 

Our Knowledge of them. — No more important question presents itself 
in medicine than the relationships of rheumatism to heart disease, and yet 
we find that this knowledge has been in possession but a comparatively 
short time. To be sure, many early, even very early, authors refer to 
" rheumatism of the heart," but their references to the condition are so 
vague and uncertain, that any one may satisfy himself that their knowl- 
edge is unimportant to us and was quite useless to them. 

It will be found that Bouillaud, by publications between the years 1830 
and 1840, was the first one to place the relations of articular rheumatism 
and cardiac diseases on a firm and useful basis. Since his time great ad- 
ditions have been made to our acquaintance with the conditions and 
changes in the heart, though but little advance has been effected, except 
in the manner of viewing the subject, in the essential nature of this rheu- 
matic process. 

Since his time the recognition of the coincidence of heart disease with 
acute rheumatism has been firmly established — nay, it has created an en- 
tirely new item in the science of medicine. Lesions of the heart, until 
then in great degree uncertain, were regarded as accidental effects of quite 
unknown origin. His researches, aided by the previously developed arts 
of auscultation and percussion, turned a flood of light on a new and 
wholly unknown field of medical work, which since then has become one 
of the most important in medical observation. 

Their Frequency. — The frequency of the occurrence of cardiac disease, 
caused by rheumatism, becomes a most important question for determi- 



COMPLICATIONS, OR EXTRA- ARTICULAR LOCALIZATIONS. 123 

nation. It was stated by Bouillaud that the cardiac complications are the 
rule in severe acute rheumatism and their non-occurrence the exception, 
while in mild cases their occurrence is the exception. 

This rule, as absolutely and simply stated by Bouillaud, is entirely 
misleading, although, like so many generalizations, it is possible to defend 
it. But as our knowledge of, and at the same time, our greater capacity 
for the recognition of the various forms of cardiac disease have advanced 
so have the exceptions to Bouillaud's law increased, until they themselves 
have almost become the law. 

The objection to Bouillaud's rule is that a belief in its entire truth tends 
to throw an inexperienced observer off guard. Unquestionably the risk that 
a patient, subjected to a severe and prolonged attack of rheumatism, runs 
of more or less grave cardiac mischief is exceedingly great, nay, almost 
amounts to a certainty, and the exceptions to the rule are few, and with 
our advancing ability of their recognition have become fewer. The more 
accurately the subsequent medical history of such cases is traced the num- 
ber of them will be found to diminish still further. 

Cases of acute rheumatism, with only a single joint involved, and those 
attended with very mild general symptoms show so great a liability to car- 
diac inflammation that it is much safer to have no rule than one which is so 
faulty, and one which leads to errors so grievous in their consequences. 

The numerical comparison has almost always been made in respect to the 
number of cases of acute rheumatism in which cardiac complications occur, 
and these statements, furnished by various authors, collated from all grades 
of cases, show a very great proportion in which a heart affection makes it- 
self known. If, as at present, we are to look upon the visceral involve- 
ments as one of the localizations of the disease other than a complication, 
strictly speaking, the comparison should be made to ascertain the relative 
frequency of heart localization to the localizations in each of the joints. 

Statistics of this sort may have some general interest, but practically 
they are of almost no value. Face to face with an individual case of rheu- 
matism they may be even misleading and take away attention from a press- 
ing danger. Should the statistical table show that in only seventy-five per 
cent, of cases the heart became affected, the tendency would be in just that 
proportion to overlook the information to be derived from physical exami- 
nation of the organ. Numbers will not help us either in the diagnosis or 
treatment. 

While it is true, as statistics tell us, that cardiac involvements are more 



12 J: RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

frequent in the severer cases, still the records show that, even in the 
mildest form of acute rheumatism, valvular lesions occur, and these may 
precede the articular inflammation, or even be the sole localization of the 
rheumatic process. The likelihood of cardiac inflammation is vastly in- 
creased during the early years of life, and this risk diminishes, but does 
not disappear, with advancing years ; up to the age of twenty-five it remains 
very great. 

Numerical accuracy in determining the number of instances of cardiac 
complication in acute rheumatism is difficult of attainment. In the first 
place, nearly all cases in which more than one acute attack occurs must 
be excluded from the computation — and these form no inconsiderable part 
of the whole number. They are excluded because when a distinct cardiac 
lesion has occurred, it becomes a difficult or impossible matter to deter- 
mine the reappearance of acute inflammation in subsequent attacks. In 
the second place, the determination of the occurrence of the heart mischief, 
in its various forms, is not an easy matter, especially in the slighter 
forms. Observers are not agreed in the matter, and what by one would 
be regarded as an indubitable sign would be doubted by another. Then, 
again, during one year the heart lesions come in nearly every case, while in 
other years cases of equal severity show little tendency to cardiac complica- 
tions. The observations must therefore be extended over long periods of 
time, and allowances must be made for these possible sources of error, 
before a true conclusion can be arrived at. 

Various Forms of Cardiac Lesions Collectively. — The consideration of 
the cardiac complications of rheumatism present themselves for study 
naturally under three heads : 1, Endocarditis ; 2, Pericarditis ; 3, My- 
ocarditis. These three forms frequently occur in combination or con- 
junctions. Thus, the first two may, and are not infrequently found in 
conjunction with each other, while a combination of the third with either of 
the other two, especially pericarditis, is almost a necessity in the more se- 
vere cases, and probably in no case is wholly absent. 

Although the relative frequency of the cardiac complications, taken col- 
lectively, to the whole number of cases of rheumatism is difficult or impos- 
sible to compute, and not of very great practical importance, the relative fre- 
quency of the individual heart-lesions is pretty well determined and is of 
great practical importance. Nearly all writers make the statement that 
endocardial inflammation occurs with very considerably greater frequency 
than pericarditis, and this is undoubtedly true as shown by records. Some 



COMPLICATIONS, OR EXTRA-AKTICULAR LOCALIZATIONS. 12 J 

authors are inclined to doubt it, or at least to think that pericarditis is 
nearly as frequent. 

Their Relative Frequency and Combinations. — It is natural, perhaps, 
that endocardial inflammation should be diagnosed more frequently than 
pericarditis, for two reasons — and this refers especially to the slighter 
cases of the two diseases. First, because valvular murmurs are more easy 
of recognition, since they are alterations of definite normal sounds, and 
also that, once developed, they remain more or less constant ; once pro- 
duced, the roughness remains and maintains a murmur-producing surface 
in contact with the blood-current. And then, too, it must be taken into 
consideration that the diagnosis of endocarditis may be an error ; for inor- 
ganic or functional murmurs are not infrequent in acute rheumatism. 
This mistake would increase in proportion with the frequency with which 
the diagnosis is made. Whereas, in pericarditis the friction-sound may 
never be heard, or having been heard, may disappear. The roughened 
serous membrane may be there, but its two surfaces be separated by a thin 
layer of serum, not sufficient in amount to increase the area of dulness, but 
enough to prevent the rubbing of the heart on the sac. This, and other 
considerations, familiar to all acquainted with post-mortem appearances, 
indicate how it is possible for endocarditis to show a preponderance in 
diagnosis, while pericarditis in reality may more nearly approach it in 
actual frequency. However, conversely to this view, the pericardiac 
sounds, if loud and extensive, may conceal the lesser blowing murmurs 
of the valves ; doubtless this not infrequently occurs, since the two lesions 
are frequently coexistent. 

Individual Lesions and their Frequency. — Go far let these remarks apply 
to cases of cardiac disease, for the recognition of which we depend on the 
physical signs rather than the symptoms, and therefore necessarily to the 
milder type of rheumatic cardiac inflammation. Of the graver cases of 
heart complication in rheumatism — cases which, by their severity, in the 
first place give rise to easily perceived or marked symptoms, and secondly 
alter the course of the rheumatic attack, prolong it, and require active 
treatment to subdue or even to conduct the patient to immediate recovery 
— the statement stands quite differently. Then pericarditis comes to the 
front, with its greater suffering and more immediate danger to life, and 
requiring oftentimes all the skill at our disposal for successful treatment. 

Endocarditis may, on the other hand, when existing alone, cause com- 
paratively little discomfort. The patient may in severe endocardiac inflam- 



126 

mation — severe as evidenced by the quantity of the valvular murmur— be 
comparatively comfortable and the pain due to the heart-lesion be infinitely 
less than the articular suffering. The patient may not know of the new 
malady, although the physician recognizes, from the physical signs, the 
grave peril threatening the valvular structures. 

This relation of affairs to the condition of the patient is explainable on 
an anatomical basis. The space over which the lesion extends in endo- 
carditis is excessively limited, while in pericarditis it is usually coextensive 
with the large area of the pericardiac sac. It is natural for the more widely 
extended inflammation to be attended with effects more perceptible to 
the patient. It is not infrequent to discover an endocarditis unexpectedly, 
by its physical signs. A pericarditis makes itself known by its symptoms. 

In respect to inflammation of the muscular substance of the heart, in 
connection with acute rheumatism, our information is quite scanty and 
wholly incomplete for the purpose of its clinical recognition. 

In a severe form, or occurring independently of the other two lesions, 
it is certainly infinitely more rare than either of them. As already said, 
its appearance coexistently with these lesions, to a greater or less degree, 
nearly always takes place. Post-mortem evidence shows that the inflam- 
mation of the pericardium extends to and affects the muscular substance 
of the heart ; in endocarditis it does likewise, though much less frequently. 
The cases are very rare — in fact, I have only met with one or two un- 
doubted instances — where the inflammation could be looked upon as a 
primary disease of the muscular tissue. 

The myocarditis, coexistent with the serous inflammations, must un- 
questionably intensify the symptoms of those lesions, but to precisely 
what degree is uncertain, since the symptoms of the muscular inflamma- 
tion are themselves unknown. 

Time of their Occurrence and Concurrence. — A question of very great im- 
portance is the time which these lesions manifest themselves in the course 
of acute rheumatism. It is now a general belief that the cardiac localiza- 
tion does take place, in certain cases of rheumatism, prior to the advent of 
the articular inflammation. In fact, some writers hint at cardiac disease 
of a rheumatic character, unattended throughout with joint manifestations, 
and even without any general symptoms. If this were true it might serve 
to explain the origin of many cases of valvular heart disease, or of pericar- 
dial alterations from which can be elicited no history of acute cardiac 
symptoms or of other acute disease. 



COMPLICATIONS, OR EXTRA- ARTICULAR LOCALIZATIONS. 127 

Symptoms of Endocarditis. — Of the individual lesions, endocarditis, in 
the majority of cases, makes its appearance early in the rheumatic attack. 
It is not infrequent to find it coming on within a few days, or even a 
shorter period, after the commencement of the fever. In hospital cases, 
entering the wards during the height of the illness, the endocardial signs 
are found already present and often advanced. The patient, once safely 
landed in the hospital ward, is thought to have avoided one great source 
or cause of cardiac mischief, viz., the excitement and pain resulting from 
transportation, which influence unfavorably the heart's action. 

But no period of an attack of acute rheumatism, no matter what the 
severity, is free from the danger of endocarditis, and of course it occurs 
independently of the patient being moved or not, whether he is in the 
hospital or is moved to its wards, whether he is surrounded from the be- 
ginning of the attack with every necessity and comfort, or is placed in 
want and misery. 

The poorer classes, however, seem to suffer more frequently than the 
richer. Such is my own experience. It is rare for endocardial inflammation 
to commence after the general symptoms have subsided, but I have known 
the murmurs to start at this time and be followed by subsequent chronic 
valvular insufficiencies. In such cases, it must be supposed that acute 
changes were present during the height of the disease. 

Symptoms of Pericarditis. — Pericarditis usually is developed much later 
than endocarditis. In the majority of cases the second week of attack sees 
its manifestation if it occurs ; and often, unlike endocarditis, its advent is 
postponed to the termination of the disease, whenever this may come. 
The pericarditis thus developed prolongs very greatly, oftentimes, the 
convalescence of the patient. In the severe cases of rheumatism where 
there seems to exist a predisposition, as it were, to cardiac complications, 
the endo- and peri-cardial inflammation may both be developed early and 
simultaneously, or one of them may precede the other by only a very short 
interval. In fact, no rule can be laid down in these cases for the order of 
their occurrence, and it should be remembered that just as a subsequently 
developed pericarditis may mask the previously existing endocardial signs, 
so a subsequently developed endocardial inflammation may be concealed 
under a prior pericarditis. 

It must be remembered that rheumatic cardiac diseases may in their 
turn give rise to complications directly connected with themselves and not 
strictly dependent on the rheumatic process. "We allude to such as em- 



128 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

bolism of other viscera, connected with endocarditis on the one hand, and 
to the extension of the inflammation from the pericardium to the pleura 
and lungs. But of these notice will be taken later. 

Briefly the phenomena which notify us of the existence of endocarditis 
are as follows : The symptoms perceived by the patient are often slight 
or entirely absent, and their grade varies with the severity and extent of 
the inflammation. At most, there is felt an uneasiness or pain at the prse- 
cordia, some difliculty in respiration is experienced, the heart may beat 
with greater force or its action may be irregular, and the pulse may not be 
found to correspond in time or force to the heart's action. The patient is 
frequently seen with an anxious aspect ; with the concurrence of all 
these conditions the face may be turgid also, and there may be headache, 
with possibly slight wandering of the mind. The fever is usually aug- 
mented, but this increase is not marked and may be overlooked or masked 
by the simultaneous involvement of a new joint, which would influence the 
temperature-curve to a greater degree than the endocarditis. Bemember 
that the area of an inflamed valve is much less than even a metacarpal joint. 

The general symptoms, both subjective and objective, are so slight, ot 
so lacking in uniformity, that it is from the physical signs the diagnosis of 
endocardial inflammation is arrived at. A constant blowing murmur, usu- 
ally soft, heard at the aortic or mitral valves, coming on during the course 
of the rheumatism, is the only condition which positively allows of this 
conclusion. If we cannot observe the development of the murmur, a 
doubt exists of prior origin of the valvular disease ; if it is not constant, 
its cause may be functional and not organic. The soft character of the 
blowing sound is an essential feature of a simple endocarditis with vegeta- 
tions, since the character of the lesions in the acute stage cannot produce 
a harsh sound. The auditus eruditus is more serviceable in determining the 
nature and character of the sound than can be conveyed by description. 
A very great familiarity, aided by the symptoms alone, will, if at all, 
lead us to the correct determination of the presence of an acute inflamma- 
tion in an already spoiled heart-valve — a condition very apt to recur in 
second attacks of acute rheumatism. 

Acute rheumatic endocarditis may occur without the blowing mur- 
mur being present. The occurrence of the murmur shows merely that 
the surface of the valves over which the blood flows is roughened by 
swelling, the products of inflammation, or the collection of fibrinous vege- 
tations from the blood. The inflammation of the lining membrane of 



COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS. 129 

the ventricular cavity, almost solely the left one, may occur, as well as of the 
tissue composing the openings and their valves, though its occurrence in 
this situation is infinitely more rare in the former than the latter. Unless 
the inflammatory roughening is near the valvular opening, the blood-cur- 
rent does not produce any sound which can be detected. The symptoms 
which result from the ventricular lesions come much later in the course 
of the disease usually, and manifest themselves, if at all, more strikingly 
in other parts or organs than the heart itself, until the fatal issue arrives. 
The condition of ventricular endocarditis with ulceration (ulcerative endo- 
carditis) is so constantly attended with the formation of fibrinous clots that 
embolism is more frequent from it than from valvular roughening in its 
earlier stages. The disease is very rare, as compared with valvular lesion 
in rheumatism, and is probably of more common occurrence in other dis- 
eases than as the result of the rheumatic process. Ulcerative endocar- 
ditis is usually fatal at an early stage, and evidences itself by more strik- 
ing phenomena, both of the heart and also in general, than either inflam- 
mation of the lining or the covering of the organ. It is frequently 
unattended with physical signs which can be detected by the ear. 

In pericarditis we have the usual symptoms of an inflammation of a 
serous membrane, modified by the anatomical peculiarities of this sac and 
the vital organ which it contains. The general condition does not differ in 
any marked respect from that of endocarditis. The pain is apt to be 
greater, and there may be more dyspnoea, especially from the pressure of 
the distended sac. But, as in endocardial inflammation, the disease may 
be recognized first through its physical signs. The single or double fric- 
tion-sound may be found during a casual examination of the chest, and 
then may disappear. Later, the area of precordial dulness may be found 
increased, together with other signs of the presence of fluid, and then the 
valvular sound may become distant or muffled, though, when heard, re- 
mains sharp if concurrent endocardial inflammation does not exist. 

The termination of the two forms of inflammation, and the influence 
which they exert on the course and severity of the rheumatic attack, as 
well as on the future well-being of the patient, stand out in most striking 
contrast to each other. Endocarditis, simple and uncomplicated with its 
own accidents, does very little to prolong the rheumatism or increase its 
severity, and it tends to terminate simultaneously with the amelioration of 
the articular inflammation. But its after effects are most unfortunate and 
generally result in permanent and ever- increasing disablement of the val- 



130 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

volar apparatus. Of course there are exceptions to this rule, and cases of 
well-raarked constant murmur become perfectly well and entail no subse- 
quent changes in valves. We may say of it — often mild during the course 
of the rheumatic attack, permanently dangerous to life ever after. 

Of pericarditis, on the other hand, it is often quite the reverse. If se- 
vere, it tends suddenly to make the symptoms grave ; coming on later in 
the illness than the inflammation of the lining membrane, it tends to pro- 
long the attack and to postpone, often very greatly, convalescence. Its 
termination resulting in complete repair, or by more or less complete 
adhesion of the two surfaces, it produces a condition which is difficult of 
recognition and without well-known or only inconstant subsequent effects 
or symptoms. Eecovery from it may be perfect, and if the adhesions are 
complete there is no possibility of its recurrence in subsequent attacks of 
rheumatism, whereas in endocarditis renewal of inflammation or further 
changes in the valves are the rule. The simultaneous or successive occur- 
rence of the inflammation in both of these parts increases in an undue or 
disproportionate manner the influence which either alone has on the course 
of the rheumatic disease, but even then the pericardial lesion seems to ex- 
ercise a preponderating effect and may lead, as it sometimes does singly, 
to a fatal termination by compressing the heart and interfering with the 
circulation. And when the two inflammations concur, it seems that the 
muscular structure of the heart tends to be more deeply affected ; and this 
occurrence increases, so far as we can judge, the symptoms and exercises 
a specially untoward effect on the course and termination of the attack. 

Rheumatic Localizations in the Vascular System. — The complications of 
rheumatism on the side of the circulatory apparatus, outside of its central 
organ, have received very little attention, and but little is known of their 
existence. In the first place, the study of such condition is attended with 
difficulty and the symptoms which disease of the vascular system, likely to 
result from acute rheumatism, would produce in the vessels, or the physi- 
cal signs which such changes would be productive of, are most difficult to 
ascertain during life. Let us think for a moment of the difficulty of 
recognizing a thoracic aneurism, either by the symptoms or the physical 
signs, or how completely every highly marked atheromatous disease of 
all arteries, except the superficial ones, almost wholly eludes discovery, 
and we can at once conceive of the almost impossibility of discovering 
slight acute alterations of the vascular system in the course of an acute 
polyarthritis. In the second place, it is probable, nay certain, that rheu- 



COMPLICATIONS, OR EXTRA- ARTICULAR LOCALIZATIONS. 131 

matic vascular changes, if such exist, are, like endocarditis, at first only 
slight in degree, and like that disease are productive of changes or leave 
behind them conditions which, slowly increasing in their effects, are dif- 
ficult to trace to their source. 

There is nothing improbable in supposing that an arteritis — a peri- or 
end- arteritis — should occur as the result of acute rheumatism, or from the 
chronic form of the disease. The tissues involved and the conditions to 
which they are submitted are very much the same. It is certain, also, 
that we see frequently enough alterations of the coats of the arteries which 
could readily be accounted for by an acute inflammation similar to that of 
a rheumatic origin. The symptoms of a local, or even general disease we 
can readily believe could escape detection, and the presence of the diseased 
condition may help to explain cases of embolism which sometimes seem to 
occur without the detection of valvular endocarditis with vegetations. 

With respect to the venous trunks and their ramifications our knowl- 
edge is equally imperfect. However, on the one hand, while our knowl- 
edge of the venous alterations seen post-mortem is less extensive, on the 
other hand we are more acquainted with symptoms ante-mortem, which 
come in the course of acute rheumatism and which could be the results of 
rheumatic localizations in these vessels, than with symptoms connected with 
the arterial trunks and their branches. 

In a very mild form, in truth, it is no unusual thing to see appearances, 
in the course of acute rheumatism, which can only be accounted for on 
the ground of a localized phlebitis. This is generally visible around an 
inflamed articulation, and the condition may extend to the larger venous 
trunks of the whole of one or more of the extremities. In fact, as I write 
I have under observation a patient who exhibits on the dorsal surface of 
the hand changes in the veins, which commenced during an attack of 
acute rheumatism. The result is that one, or perhaps two, of the larger 
superficial vessels on the ulnar side have been closed, or at least thick- 
ened, by inflammatory alterations, and at one point is felt a hard mass, 
like a phlebolite. Alterations of the veins are by far more common in gout 
than in rheumatism. Allusion may also be made in this connection to> the 
changes seen in the smaller vessels of the brain, and even in its venous 
sinuses, in fatal cases of cerebral rheumatism. 



CHAPTEE XII. 

COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS. — Continued. 

Respiratory Apparatus : The Parts Affected and the Frequency of their Involvement ; 
Pleurisy, its Character and Duration ; Pneumonia, its Relation to the Rheu- 
matic Process ; its Type and Grade ; Mucous Membrane Inflammations, their 
Relationship to the Tissues Ordinarily Affected in Rheumatism ; Rheumatic 
Angina ; Bronchitis and Broncho-Pneumonia — Digestive Apparatus. 

Respiratory Apparatus. 

Tlie Parts Affected and the Frequency of their Involvement. — Pleurisy 
and pneumonia, as well as other morbid conditions of other portions of 
the respirator^' apparatus, occur as complications of acute rheumatism. 
Some of these, especially the first, while not absolutely rare, are very much 
less frequently seen than cardiac disease. Pleurisy is by far the most com- 
mon of them, and herein it exhibits, with similar inflammations coming in 
the adjoining serous sac of the pericardium, the general tendency of the 
disease to involve the fibrous tissues. These two serous membranes are 
not infrequently found communicating the inflammatory condition the one 
to the other. Almost every portion, however, of the respiratory apparatus 
is liable to be involved. 

To determine the frequency of respiratory complications is even much 
more difficult than it is to answer this question concerning the cardiac 
localizations, and this is especially so in pleurisy. A thorough examination 
of the chest, which is necessary sometimes to show the existence of the 
pleural disease, is almost impossible, often on account of painful articula- 
tions. Hence, many cases are unquestionably overlooked. The symp- 
toms of pain and difficulty in respiration are doubtless many times set 
down to muscular rheumatism and neuralgia. 

Pleurisy, its Character and Duration. — Pleurisy is probably more fre- 
quent on the left side than on the right, apparently without discoverable 
cause. Sometimes it results from direct extension of the inflammation 



COMPLICATIONS, OK EXTRA- ARTICULAR LOCALIZATIONS. 133 

from the pericardium through the walls of the sac, and I have seen the 
complication result also in the right pleural sac by the same process. 
Doubtless many slight localized pleurisies coexist with pericarditis and 
escape detection in the presence of the more grave malady. 

A considerable number of well-marked double pleurisies, however, are 
found in acute rheumatism, which are developed independently and apart 
from any cardiac complication, or at least are not dependent on thi3 as their 
direct cause. I am inclined to think that rheumatic pleural inflammations 
produce inflammatory materials of a less serous and more fibrinous char- 
acter than is common in perhaps the majority of cases of idiopathic pleu- 
risy. Whether the inflammatory effusion contains much or little fibrin 
we have but few opportunities of determining post-mortem, but certainly 
when fluid is present its absorption takes place readily and promptly. 
Very few instances — relatively to the whole number of cases of pleurisy or 
absolutely in those occurring in acute rheumatism — pass over into a chronic 
state, with empyema or other disastrous conditions. Perhaps it may be, 
as shown from the fibrinous condition of the blood, that fibrin or adhesive 
lymph is present in increased amount in the effusion of rheumatic pleurisy, 
and that through its agency adhesions, and the consequent cessation of 
the pleural disease, take place more promptly. It may be that the in- 
flammatory process ceases here, as in the other localizations, with the 
abatement of the general symptoms of the rheumatic disease. However, 
in some cases of pleurisy which I have seen, post-mortem, the thickness of 
the pleural lymph v^as very great and also of very firm character, and the 
inflammation had been continued in a chronic manner with recurrences 
on the reappearance of the rheumatic symptoms. In another instance, 
seen post-mortem, there was little or no tendency to the formation of 
fibrinous material ; it was a truly empyemic case and the lymph could only 
be described as cacoplastic. The patient was, previously to the rheumatic 
attack, in a debilitated condition. We must conclude, therefore, that this 
inflammation is not of a uniform type, but is modified by unknown condi- 
tions, and especially by the general state of health of the patient. 

Pneumonia, its Relation to the Rheumatic Process ; its Type and Grade. 
— Pneumonia is a much less common complication of the rheumatic pro- 
cess than pleurisy. So far as I have seen it, the gravity of the complica- 
tion was of slight character and was connected with a coexistent pleural 
inflammation, on which the pneumonia apparently depended for its origin. 
The records of the cases of pneumonic complications of rheumatism point 



134 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

rather to the occurrence of the catarrhal form of this disease than to the 
croupous. The only instance which I have seen post-mortem occurred in 
connection with chronic rheumatic pleurisy, and was of a mixed croupous 
and catarrhal character. The partial hepatization of the lung-tissue seems 
to be due to an extension of inflammatory irritation from the pleura to the 
alveolar trabecule, causing a catarrhal condition of the air-vesicles, and, 
when of a high grade, a fibrinous exudation also. Hypostatic pneumonic 
solidifications are not infrequent. 

IIucous Membrane Inflammations, their Relationship to the Tissues Or- 
dinarily Affected in Rheumatism. — The other forms of the rheumatic com- 
plications of acute rheumatism affecting the respiratory apparatus are 
mucous membrane inflammations, so called, and the kind of pneumonia 
above spoken of shows its affiliation to these other catarrhal inflammations 
seen in the upper portion of the respiratory tract. Rheumatism generally 
shows a tendency most strikingly to affect the fibrous tissues, such as the 
pleura, peri- and endo-cardium, as well as the articular structures, and al- 
though here the chief phenomenon is a catarrhal process, still the same 
tendency is, I think, exemplified, for it is apparently the submucous con- 
nective tissue or even the deeper tissue which first receives the morbid 
rheumatic influence, rather than the epithelium ; the latter, by its close 
approximation, becomes involved as the irritative changes develop in the 
former. Of these bronchitis is the most frequent ; a tonsillitis and a phar- 
yngitis also have been described. 

A well-marked inflammation of the mucous membrane of the pharynx 
is probably a not infrequent complication of acute rheumatism, but it is 
either overlooked or its true nature and significance remain unknown. It 
is unquestionably many times regarded as the effect of the cold or damp- 
ness which produces rheumatism, and such attacks are at first looked upon 
as a simple case of " catching cold," or " sore throat," but on the later 
development of the rheumatism are disregarded. In other instances, the 
throat affection is unheeded in the presence of the graver malady. 

Rheumatic Angina. — The condition of the throat usually spoken of as 
an angina has been carefully studied and described by Lagoanere (1876). 
The disease is developed in the very beginning of the rheumatic attack 
and even may be found in some cases as a preliminary or prodromic 
symptom. Much more rarely it continues after the development of the 
articular inflammation. It usually appears with the onset of the fever, or 
attention is called to it just after the occurrence of this symptom, so that 



COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS. 135 

its relationship, in point of time, may appear the same as that of an or- 
dinary febrile sore throat. 

The angina comes suddenly with a feeling of stiffness or pain in the 
region of the palate, especially provoked by movements, such as swallowing, 
speaking, and even by movements of the neck and head. The pain extends 
toward the ears, or upward to the nasal region and the forehead, provided 
the inflammation reaches in either of these directions. The muscles of the 
neck may become slightly stiff, as in torticollis, and sometimes the glands 
at the angle of the jaw and below are enlarged. 

The throat presents a diffuse erythematous redness of not very intense 
character, and the mucous membrane is swollen, especially the uvula. 

Its course varies ; ordinarily the appearance after full development re- 
mains fixed in the place affected, and sometimes it extends to the nasal 
and aural structures, or to the tracheal and bronchial mucous membranes. 

The diagnosis is decidedly retrospective, and the condition finds its 
explanation through the rheumatic inflammation making its appear- 
ance in the joints. To some patients, well experienced in acute or 
subacute attacks, the angina is diagnostic, or rather prognostic, of such 
attacks. The appearances presented by the throat are not characteristic, 
and a dependence on the nature of the occurrence rests on antecedent and 
concomitant circumstances. The attendant symptoms, too, are usually 
greater than warranted by the condition of the throat. There are only 
two conditions, except a simple cold, with which a rheumatic angina could 
"be confounded, viz., erysipelas and scarlatina, but from these diseases it 
can readily be distinguished by the characteristic symptoms of those mal- 
adies. 

The nature of angina seems to find its explanation in the similar in- 
flammatory conditions which occur on the skin in acute rheumatism. In 
the one the rheumatic process affects the external epithelial covering, in 
the other the mucous membrane exhibits very similar appearances. 

Its course is always benign and is usually lost in the severity of the 
rheumatic symptoms by which its nature is made apparent and into which 
it generally fades as they develop. 

Bronchitis and Broncho-Pneumonia. — The bronchial complication of 
rheumatism presents nothing to attract special attention, but if it becomes 
severe the agony of the patient from the racking cough is almost unbear- 
able. The bronchial inflammation occasionally leads on to broncho-pneu- 
monia, and this condition may be followed by a pleurisy. 



136 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Digestive Appabatus. 

The digestive organs give rise to very few symptoms during life, and 
after death show few changes which can be attributed to the effects of the 
rheumatic process directly. Allusion has been made to the rheumatic an- 
ginas and coryzas, and these conditions have been observed to affect the 
oesophagus. Difficulties in swallowing, with or without pain, have been 
pointed out during the course of acute rheumatism ; which have been 
attributed to a localization of the disease in the muscular apparatus of the 
oesophagus. The stomach and intestines very rarely give symptoms 
other than those common enough in any febrile malady. The gastralgia 
and enteralgia, not unfrequently spoken of, are symptoms easily con- 
founded with localizations in surrounding parts, especially the diaphragm 
and the abdominal muscles, and must therefore be regarded as of doubtful 
character. The inflammatory lesions of the mucous membrane of the di- 
gestive tube, signalized by diarrhoea, dysentery, or hemorrhagic dis- 
charges, much more frequently precede or follow than accompany acute 
rheumatism, and the rheumatic inflammation is to be looked upon as a 
sequel of such diseases, or as a distinct attack due to veiy similar causes. 

The liver is sometimes found increased in size after rheumatic fever of 
a severe and long-continued character. But of the symptoms and changes 
of function of this organ we know so little positively, except in obstruc- 
tive disease of its ducts, that we are entirely ignorant of its condition, 
equally in rheumatism as in other diseases. 

The peritoneum, from its anatomical structure, deserves consideration 
in connection with the fibrous connective tissue rather than with the diges- 
tive apparatus proper. This, the largest of the serous membranes, how- 
ever, requires almost no attention in acute rheumatism ; a few cases only 
are on record in which post-mortem inflammatory changes have been found 
in it. Such instances acquire importance by showing the wide, almost 
universal extension of the rheumatic influence rather than from the likeli- 
hood of being encountered clinically. It is probable, however, that an 
effusion of serum not infrequently occurs in the peritoneal cavity, but this 
is airparently of a non-inflammatory character. The condition seems to 
occur in cases where a similar effusion is found in the pleural cavities, or 
in which other localized or general cedemas are seen. Occasionally a peri- 
toneal effusion follows a rheumatic pleurisy or pericarditis. 



CHAPTER XIII. 

NERVOUS COMPLICATIONS. 

Symptoms — Acute Inflammatory, Cerebral, and Meningeal Lesions — Cerebral Rheu- 
matism — Hyperpyrexia — Other Nervous Symptoms — Rheumatic Cephalalgia — 
Vertigo — Conditions which Tend to Produce Cerebral Symptoms and Lesions. 

Symptoms. 

In acute rheumatism the symptoms connected with the nervous system oc- 
casionally present themselves and form one of the gravest conditions of this 
malady. The cases with nervous complications divide themselves pretty 
naturally into groups and sub-groups, which, while acknowledging a com- 
mon cause, differ so radically in some of their striking features as to ap- 
pear quite dissimilar and even disconnected. 

In acute rheumatism we can distinguish, in the first place, two great 
classes which are attended with nervous symptoms — one in which inflam- 
matory or other lesions of the brain or spinal cord or their meninges are 
present ; another in which the nervous phenomena are dependent on the 
general conditions of the malady. As yet no very obvious, or at least 
marked lesions of these tissues have been pointed out, but nevertheless, 
in many of these cases marked lesions of the vascular or other organs are 
present. 

The accurate differentiation of these two classes is a matter of great 
difficulty. Doubtless, in former times cases of the latter class were fre- 
quently attributed to meningitis or cerebritis, which now with our greater 
knowledge and more extended observation would not be thus mistaken. 
Cerebral rheumatism without brain lesions is now a well-recognized form 
of the malady, as our knowledge of the symptoms of meningitis has be- 
come more accurate. 

The two anatomical classes do not, however, afford convenient divisions 
under which to study clinically these phases of rheumatism, although 
the distinctions which we have just made are essential to be borne in 



138 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

mind for a correct appreciation of the various forms of the malady and 
their treatment. 

There are four principal groups of cases which represent the various 
forms in which the nervous symptoms appear. 

First. — The acute inflammatory and similar changes of the brain and 
spinal cord and their membranes. 

Second. — Cerebral rheumatism proper, in which the symptoms occur 
during the course of the disease but which do not furnish evidences post- 
mortem of inflammation or other appreciable changes of the brain or its 
membranes. Sometimes the small cerebral vessels are altered, but much 
more frequently other organs are the seat of lesions which are supposed 
to be directly or indirectly the cause of the nervous phenomena. 

Third. — Hyperpyrexia. This condition may be thought to be a sub- 
division of the second group, but I prefer to separate it, because it may 
have merely the one essential and all-important feature, viz., the exces- 
sive temperature, which is almost always lacking in the cerebral rheuma- 
tism group. 

Fourth. — A set of nervous symptoms which may occur in both acute 
and chronic rheumatism. They may develop during the acute attack or 
during convalescence from it. Some of these symptoms are seen in pa- 
tients who exhibit at the time little or no evidence of the ordinary rheu- 
matic condition. The phenomena are supposed to be due to the same 
process, although no articular inflammations are present. 

1. Acute Inflammatory, Cerebral, and Meningeal Lesions. 

The certain recognition of cerebro-spinal lesions in acute rheumatism, 
is often, as in many other acute diseases, a matter of great difficulty ; per- 
haps even greater than in most others. Because in many of the diseases 
attended with nervous phenomena we know by extended experience that 
no lesions which can be recognized as the cause of the delirium, etc., are 
exhibited. Therefore the conclusion has been reached that such symp- 
toms are only epi -phenomena of the disease. 

In any case of rheumatism, attended with nervous symptoms — and it 
is only in acute cases that these occur — meningitis is the least likely cause. 
Cases are on record, however, where post-mortem evidences of inflamma- 
tion have been found — the membranes and the surface of the brain show- 
ing injection, with lymph or pus — but they are few in number, very few 



NERVOUS COMPLICATIONS. 139 

even in proportion to the whole number exhibiting head symptoms, which 
are themselves by no means abundant, and probably even less so now 
than formerly under a different mode of treatment. 

By some the rheumatic nature of even these cases is denied and the 
condition has been looked upon as an intercurrent attack of meningitis 
rather than a localization, or a complication dependent on rheumatism. 

The spinal cases are of even less authenticity than the cerebral ones. 
Inflammation of the vertebral joints and pains in the posterior trunk mus- 
cles are comparatively common, and the former may even extend to or 
affect the closely lying tissue within the spinal canal, or by pressure affect 
the nerve-trunks at their points of exit, giving rise to some phenomena 
closely simulating spinal inflammatory changes. It is likely also that cases 
of spinal meningitis, of different origin, perhaps, from cold or exposure, 
and even epidemic cerebro-spinal meningitis have been mistaken for acute 
rheumatism of irregular type. 

Under this class of complications we must refer to the " chronic rheu- 
matic disease of the brain " which was first described by Griesinger (1860, 
Arch.f. Heilk.). The cases express themselves by symptoms of mental 
disturbance, in the strict or narrow sense of the term, and not so much 
by phenomena which are usually connected with meningeal or other gross 
lesions. In these cases, the few that have been examined post-mortem, no 
distinctive or plainly causal lesions have been shown to exist, but still I 
think we may as fairly attribute them to actual, though unknown, altera- 
tions as we are in the habit of doing in other cases of insanity dependent 
on other causes than rheumatism. The common form of mental disturb- 
ance resulting from rheumatism is melancholia, and the condition is vastly 
more frequent, as is this disease from whatever cause, in adults than in 
children. 

The pathological alternations of all the forms of cerebral and spinal 
disturbances in rheumatism come under one or more of the following 
classes of changes : 1. The ansemias or congestions ; 2, inflammations or 
effusions of the membranes or of the brain substance ; 3, lesions of the 
vessels proper, either from embolism or thrombosis ; and, 4, softening 
or induration of the nervous tissues. 

All these lesions occur comparably more frequently in connection with 
similar conditions present in other organs, or as the result of prior lesions 
determined in other parts, than simply from the localization of the rheu- 
matic process in the cerebral centres. Certain portions of the nervous 



1-40 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

apparatus seem to be more frequently affected primarily or principally 
than others, and this preponderance is exhibited in a very striking man- 
ner. Thus the dura mater, both cerebral and spinal, are by far less com- 
monly affected in the total than any other portion. The arachnoid, the 
subarachnoid space, and the pia mater exhibit or give rise to many more 
symptoms than all the others combined. The cerebral tissue proper and 
the vascular apparatus, while not escaping from changes during the acute 
stage, show the effects of rheumatic process secondarily or as the result 
of lesions in distant organs, especially the heart. 

The anaemia and congestion, especially the former, may be divided 
into two classes, the one apparently functional, so to speak, either by ex- 
hibiting the a*ppearances or giving rise to symptoms which we usually 
connect with an ensanguined state of the vessels ; the other class including 
the essential ansemia connected with the alterations of the blood, which, 
during the rheumatic process, becomes deficient in the red-corpuscular 
element. With these conditions we may also speak of the chemical altera- 
tions in the blood, of which we know emphatically little, but which are sup- 
posed to be due to its surcharge with the rheumatic poison. 

The congestions of the cerebral substance are much more readily ap- 
preciated with the naked eye, and their effects are easily shown by the 
aid of the microscope. They are exhibited under two forms, although the 
clinical features are indistinguishable ; the effusion in which they result 
may be either of blood or of serum, and their extent may be quite local- 
ized or a general one, and their development slow or rapid. Their causes 
may be spontaneous or the results of lesions in other organs, or of lesions 
in the vessels. The result may exceed the congestive stage and proceed 
to an actual hemorrhage, simple or multiple, large or small. The hemor- 
rhagic effusions are almost invariably minute and are to be seen in the 
perivascular sheaths of terminal capillaries and also occasionally in patches 
under the arachnoid. Large cerebral hemorrhages are unknown, and the 
term apoplexy, not infrequently found in older authors in describing cer- 
tain rare cases of fatal rheumatism, cannot be attached to this lesion. It 
relates, probably, to cases whose pathology was then quite unknown, of 
hyperpyrexia or of uraemia. To these minute hemorrhagic effusions are 
closely allied cases in which the capillaries are found dilated (capillary 
aneurism), as the result sometimes of local disease of the vascular wall, 
sometimes of complete or partial occlusion of their lumen. 

The serous effusions are seen more frequently in the subarachnoid 



NERVOUS COMPLICATIONS. 141 

space or tissue than in the ventricles of the brain, but evidence is not 
wanting that fluid is effused in the substance of the brain — a perivascular 
distention which leaves its distinctive traces behind it. However, the 
anatomical arrangement is such that any considerable subarachnoid effu- 
sion is accompanied by or even produces, at least post-mortem, an abnor- 
mal amount of fluid in the ventricular cavities. The means of communica- 
tion between the surface and central cavities is afforded through the 
lymph-tracts. The more frequent occurrence of the subarachnoid fluid, 
even though a slight amount of fluid is found in the ventricles, shows a 
peripheral tendency on the part of the morbid process, which is thus in 
accord with the similar localization of the inflammatory process in the 
same part of the brain. 

The inflammatory conditions may be described under two heads or 
forms, which are convenient for analysis, but which merge into each other, 
and are not well differentiated by their clinical features. 

The least common form of the inflammation is that which exhibits 
itself by more or less abundant inflammatory or purulent products on the 
surface membranes of the brain, and extends into the cerebral tissue itself. 
It is spoken of as meningo- encephalitis. The other form is seen by the 
microscope as an effusion along the walls of the capillaries, especially the 
minute ones in the brain- substance, which appear augmented in numbers 
and often undergo a considerable dilatation in size. 

2. Ceeebkal Kheumatism. 

Acute rheumatism is regarded, and truly so, as a disease which, for its 
severity in respect to its ordinary febrile phenomena, is singularly free 
from all those symptoms of a nervous type usually spoken of as cerebral. 
The patient's mind, even in the height of the fever, is clear and the expres- 
sion intelligent. It neither inclines to any form of delirium, either active 
or low, nor is there found dulness or stupor. The vast majority of cases run 
their course without any nervous symptoms, unless we except a degree of 
sleeplessness, which cannot be described as insomnia, since it is the result 
of pain and discomfort rather than the effect of the disease on the nervous 
centres. In describing the nervous conditions or complications, therefore, 
we are describing unusual and exceptional cases. 

Of those which we propose to describe under this head, cerebral rheu- 
matism is the most important. For what I have here to relate of this com- 



142 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

paratively rare form of rheumatism I am chiefly indebted to the article of 
my colleague at the Pennsylvania Hospital, Dr. Da Costa, in the American 
Journal of the Medical Sciences for January, 1875. 

This author gives the following as a general description of cases of cer- 
ebral rheumatism : "In the course of acute rheumatic fever, usually after 
it has existed for some time, or even after convalescence and among the 
first signs of a relapse, appear symptoms of cerebral disorder, manifesting 
themselves chiefly by restlessness, passing into stupor or coma, or becom- 
ing associated with delirium. The former combination is less common 
than the latter and of much shorter duration. The delirium is preceded 
by wakeful, dreamy nights, is generally mild, and it is during the restless 
nights that it shows itself most plainly. Though it may be a continuous, 
it is scarcely ever a fierce delirium, and is not, as a general rule, linked 
either to headache, injected eye, or vomiting. It may run a rapid course, 
delirium or stupor quickly ending in coma, coma in death. But ordinarily 
it goes on for days, the patient gradually mending or becoming weaker 
and weaker, and passing perhaps into a condition very similar to that of 
typhoid fever, excepting that the bowels are constipated. The likeness to 
enteric fever is heightened by the presence of sordes on the teeth, and the 
appearence of an eruption. The temperature is apt to be high, the joint- 
affection persistent, or even showing signs of increase ; the breathing is 
rapid ; the pulse is frequent, compressible, and at times irregular'. A car- 
diac difficulty may show itself distinctly as a complication, or again be 
wholly wanting. In some cases convulsions, in others, local palsies hap- 
pen; or we may have hemiplegia even suddenly developed. But these 
features are rare ; and it is in the wakefulness and restlessness, in the 
stupor and delirium, that we mostly find the signs of how decidedly the 
bra^i has become disordered." The author in describing the malady limits 
the term cerebral rheumatism to cases in which the nervous symptoms are 
prominent and appear to constitute the real features of the affection. He 
says further that "doubtlessly occasional restlessness and some slight 
mental wandering at night are not uncommon in decided cases of acute 
rheumatism at the height of the fever, and are more likely to be found if 
there be a cardiac complication ; but such transitory and subordinate 
phenomena do not make a disorder which we can call cerebral rheuma- 
tism." 

The author further says that he does not desire " to speak of the dis- 
turbance as one complaint, when we shall find that several morbid states 



KEEVOUS COMPLICATIONS. 143 

may contribute to it," and in the general description given above it is used 
as marking the cerebral type of the malady rather than pointing out a sep- 
arate and perfectly well-defined morbid condition. 

A most interesting point in connection with cerebral rheumatism, as 
here defined, is the febrile state or temperature of the body. The cases 
recorded by DaCosta — and the few other cases scattered through medical 
literature agree with them — show that the temperature at the time of the 
occurrence of cerebral symptoms is high, and that only a slight rise of 
temperature precedes the cerebral manifestations. Subsequently variations 
are but slight, except the morning remission of about one degree, or even 
less, until recovery, or until the bodily heat increases just before death. 
The exceptions to this are when, during the course of the cerebral symp- 
toms, new joints become affected, when, as usual, a decided rise of temper- 
ature takes place ; otherwise the temperature record remains singularly 
uniform, and cerebral rheumatism, like the visceral complications, for ex- 
ample, endo- and peri-carditis, shows only slight thermometric fluctuations. 

It will therefore be seen that cerebral rheumatism, one of the forms of 
the nervous complication of the disease, differs strikingly from hyper- 
pyrexia, another of the nervous complications, in that the temperature does 
not reach an excessive height. It is necessary, therefore, to differentiate 
hyperpyrexia from the brain symptoms strictly — cerebral rheumatism. 

Of the strictly cerebral symptoms we may point out three types or 
classes : 1, stupor ; 2, delirium (usually of a mild type) ; and 3, an active 
delirium, closely resembling that of acute mania, well characterized by the 
term rheumatic insanity. It is probable that these three groups are due 
to distinct morbid causes, and show post-mortem quite distinct morbid 
changes. 

It is probable that a majority of the cases of cerebral rheumatism at- 
tended with stupor will give evidence of a renal complication, or perhaps 
pre-existing kidney disease, and that therefore the condition is not so much 
one of cerebral rheumatism or of a rheumatic disease of the brain, if 
we attempt to erect this group of cases into a well-defined morbid condi- 
tion, as it is the result of the changed function of the urine. It is, there- 
fore, the result of renal disease, either following out its ordinary results, or 
the involvement of the kidneys in a morbid condition as the result of the 
rheumatic process. 

It is not necessary to conclude absolutely that every case of cerebral 
rheumatism is the result of renal disease, since other diseased conditions 



144 

of the brain or its vessels are productive of a state of stupor. DaCosta 
points to the probability " that nearly all the so-called apoplectic instances 
of cerebral rheumatism have as their cause renal disease rather than cere- 
bral alterations ; " and also that this cause "suggests the explanation of 
many of the other nervous phenomena of " acute rheumatism. 

The second group, those attended with delirium, find likewise in many 
instances their explanation in some visceral complication other than the 
cerebral. This condition is paralleled by the phenomena which are wit- 
nessed in other diseases than rheumatism. For example, in pneumonia 
delirium of a mild type is of not infrequent occurrence, and the same, 
though much less frequent, occurs in inflammation of the serous membrane. 
In reviewing cases in this group of cerebral rheumatism, the records fre- 
quently show the occurrence of endo- or peri-carditis. 

In these cases it will be of service to note the fact that restlessness, 
which may be considered part of the delirious condition, is often more 
striking than the mental aberration, and fits in, perhaps, with the early 
observation of Dr. Bright on " cases of spasmodic disease accompanying 
affections of the pericardium," and also with the earlier and more recent 
observations on the association of rheumatic disease with chorea. 

The cause or perhaps the mode of action of the rheumatic disease in 
exciting chorea or other rnotory phenomena has been very variously 
viewed. Formerly these conditions were spoken of as true excito-motory 
phenomena caused by the rheumatic poison acting on the nervous centres. 
More recently they, and especially chorea, have been thought to be due 
to the alteration of the circulation of the brain produced by minute emboli 
of the cerebral centres. And even as yet the whole question remains in a 

very unsettled state. 

it 

3. Hyperpyrexia. 

In the third group of cases the rheumatic insanity, or those attended 
with active delirium, we shall probably find the residuum which we can 
with accuracy describe as cases of cerebral rheumatism, or a rheumatism 
of the brain, and which we could, if it were desirable, erect into a group 
forming a well defined morbid condition. To do this we must separate 
from the whole number of cases of acute rheumatism attended with cere- 
bral symptoms, on the one hand, those which may be fairly considered as 
of renal origin and also those in which the symptom is due to visceral in- 



NERVOUS COMPLICATIONS. 145 

volvement, generally thoracic and attended with delirium. On the other 
hand, as already said, the cases of hyperpyrexia frequently exhibiting head 
symptoms must be placed to one side, xind again, also, all those cases 
must be excluded in which the cerebral symptoms — and these cases are 
sometimes attended with motor disturbances of a marked type — can be 
traced to embolic occlusion of the cerebral vessels, chiefly the smaller ones. 

What then have we left to constitute our group of true cerebral rheu- 
matism ? 

Here again we must separate the rare cases of real rheumatic menin- 
gitis. The residuum is, I think, to be regarded as composed of all such 
instances in which the cerebral symptoms have been considered as due to 
the action of rheumatic poison on the brain-tissue directly, or indirectly 
through the changed composition of the blood, or perhaps by both of 
these ways. 

How the rheumatic poison affects the brain-tissue is of course unknown, 
and if it does so at all, it would seem that the cerebral phenomena should 
occur with greater frequency in rheumatism than is certainly the case. 
The instances in which cerebral phenomena appear are comparatively very 
rare, and these, too, in patients who do not evidence strongly the ordinary 
rheumatic phenomena, or else in cases during convalescence from an at- 
tack. It would seem, therefore, that if these nervous symptoms were the 
direct effect of the rheumatic process on the brain-tissue, that its effects 
would be more frequently seen both during life and on post-mortem ex- 
amination. In respect to the indirect action on this tissue, either from the 
deterioration of the blood or from its changed composition through the 
presence of the new material, we have rather more evidence to substantiate 
a belief. In the first place it falls in with our notions of what takes place 
in other diseases. Thus, in nearly all the continued fevers, under certain 
conditions, we are familiar with the occurrence of cerebral symptoms which 
cannot be traced to evident lesions of tissue. 

Then, too, we have very constant and positive evidence of deterioration 
of the blood. This makes itself apparent in a large majority of cases by 
the profound ansemia exhibited by patients. The change in the constitu- 
tion of the blood, especially its corpuscular elements, can readily be dis- 
covered by a microscopic examination, which shows a great depreciation in 
their numbers as compared with health. 

A third condition, which may properly be included under the head of 
real cerebral rheumatism, is an alteration taking place in the lining mem- 



146 KTIE UMATISM, 

brane or the walls of the minute cerebral vessels. The effect of such 
changes is to produce a partial or complete occlusion of their calibre and 
a consequent disturbance of the cerebral circulation, affecting larger or 
smaller areas of the main tissue. 

This change is thought to be due to an inflammation or degeneration 
of the vascular wall, whereby its smooth surface is roughened and presents 
itself as a favoring spot for the formation of a clot or coagulation of blood. 

This is a process of thrombosis of the cerebral vessels as distinguished 
fi'om embohsm, and how far the two conditions can be satisfactorily dis- 
tinguished requires further study. Minute emboli are at best difficult to 
identify, and it often depends upon a process of exclusion ; if no vegeta- 
tions are found upon the heart-valves or other roughened surfaces in con- 
tact with the blood-current, occlusion of the minute vessels may be said 
to be due to other conditions than embolism, although it is possible to 
suppose, and does undoubtedly occur, that under certain conditions minute 
clots form in the blood, and are carried along in its current, forming plugs 
in certain terminal vessels. The discovery of degenerative changes of the 
minute vessels of the brain, accompanied with the roughness of their walls, 
would, of course, substantiate the thrombotic origin or nature of their oc- 
cluded condition. 

It must be remembered, however, in this connection that minute or 
partially occluding emboli may, on the one hand, be wholly or partially 
absorbed, and on the other hand, by adhering to the vessel- wall, produce 
inflammatory or degenerative changes of its substance. Thus either one 
or the other of these results of embolism may present appearances or 
changes closely resembling initial vascular disease or autochthonous em- 
bolism with their subsequent changes. 

It is certain, however, that a considerable number of the post-mortem 
records of cases of cerebral rheumatism 'show evidences of occlusion of the 
brain-vessels in which no appearances of endocardial or arterial disease 
likely to give rise to minute emboli were found, and which therefore may 
be fairly set down to the account of changes in the cerebral vessels due to 
the rheumatic process. 

How far these changes of the cerebral vessels should be viewed strictly 
as cerebral rheumatism, or how far be classed with such affections, as for 
example, endocarditis, will be further considered under the head of Com- 
plications. 

It is especially interesting* to note the fact that, in nearly all the cases 



NERVOUS COMPLICATIONS. 147 

of cerebral rheumatism as here described, the brain exhibits so little al- 
teration, and none at all commensurate with the evidences of the grave 
symptoms during life. 

4. Other Nervous Symptoms. 

There are a number of symptoms of a nervous character which at vari- 
ous times, and by many authors, have been attributed to rheumatism. 
These phenomena can, in general, be spoken of as of lesser importance than 
those previously referred to, although at times they become of severe 
character or even of fatal severity. Some will be found to manifest them- 
selves during the height of a rheumatic attack, others during convalescence, 
while others, again, precede, by a greater or less length of interval, a rheu- 
matic paroxysm, or, on the other hand, become one of the sequeLe of such 
attacks. 

Among those coming in the course of a rheumatic attack, DaCosta has 
observed cases of hurried respiration. He speaks of this symptom as oc- 
curring without anything in the condition of the lungs or heart to account 
for it. He mentions the symptoms as among some of the other morbid 
manifestations met with in cerebral rheumatism, and it is a condition 
which is certainly to be observed not alone in cases of cerebral rheumatism, 
although perhaps in such cases owing to the general nervous condition of 
the patient otherwise manifested of more frequent occurrence, yet I have 
seen it in a pronounced degree in severe cases of rheumatism unattended 
with other nervous phenomena. 

Senator speaks of "certain paroxysms of palpitation and oppression 
which not infrequently occur during rheumarthritis ; they are transient, 
and do not depend on any cardiac complication." As in these cases no 
visceral lesions are evidenced by the symptoms of the organs principally 
concerned, one cannot avoid speaking of the phenomena as of nervous 
origin. 

The occurrence of death during such paroxysms has been reported, but 
must be exceedingly rare. 

I think it will be always doubtful whether such manifestations, when 
not directly traceable to some visceral involvement — especially such as 
en do or myo-carditis, as unquestionably is sometimes the case — can be re- 
garded as strictly of nervous origin in the same sense attributed to the 
other nervous manifestations here discussed. The doubt will remain 



14S RHEUMATISM, GOUT, A^ T D ALLIED DISORDERS. 

■whether they are not due to simple exhaustion, the result of pain and loss 
of rest. If due to any of these causes, they ought not to be spoken of as 
of rheumatic origin. 

Rheltjatic Cephalalgia. 

Rheumatic cephalalgia has been described by many authors, and espe- 
cially by Canstatt and Gubler, as the first form of cerebral rheumatism. 
Boerhaave, van Swieten, and Frank long ago pointed out a rheumatic 
headache, and spoke of it as one of the early symptoms of rheumatism, but 
their observations, I think, are not confirmed by the common opinions of 
later authors. 

This rheumatic headache must not be confounded, though it may very 
easily be and has frequently been so, with neuralgia and "with rheu- 
matism of the scalp. Desguin, in a communication to the Belgian Academy 
of Aledicine, gives an observation which I think may truly be regarded as 
rheumatic headache, and belonging to the group of cerebral rheumatism. 
He describes the pains as of a mobile character, occurring at various points 
of the cranium, especially at the level of the occipital and frontal promi- 
nences. The pains seem to be within the skull, and pressure on the surface 
does not modify their character, as is the case in rheumatism of the scalp. 
The muscles of the neck are more or less rigid, and the movements of the 
head painful, and at the time often the movements of the eyes cause pain. 
Conditions of coldness' and dampness aggravate the sensations as in rheu- 
matic affections of the joints. Febrile conditions are usually not present. 
The attacks, as observed by Desguin, is followed by rheumatic phenomena, 
especially of the articulations of the extremities or by alternations of head- 
ache and articular inflammation. 

Vertigo. 

A condition of vertigo of rheumatic origin, or occurring in connection 
with rheumatism, has been recognized for a long time, and is spoken of 
by many of the older authors. Musgrave, Stoll, Bang, Barthez, and J. 
Frank refer to a rheumatic vertigo, but many of these references are to a 
degree doubtful, since rheumatism in their nomenclature possessed a di- 
verse signification, and in many of their cases this symptom was unaccom- 
panied by any general affection. Herz, in 1791, was the first to differ- 
entiate the dizziness occurring in rheumatism froni the quite unlike 



NERVOUS COMPLICATIONS. 140 

condition in cases of gout, which, up to his time, had been combined under 
the head of arthritic vertigo. 

Sovet, in a memoir directed to the Belgian Academy, in 1858, was the 
first one to give an authentic account of the condition, which met the ap- 
proval of the learned body to which it was submitted. Desguin also con- 
tributes a number of cases. 

Kheumatic vertigo cannot be considered as a very important condition, 
although it may be a very striking phenomenon connected- with this 
morbid process ; it is more strictly to be looked upon as an incident of 
the disease. Its description rounds out the phenomena of the group of 
cerebral or nervous rheumatism, and it is probably to be looked upon as a 
sub-group, having to do with the spinal, rather than the cerebral manifes- 
tations of rheumatism ; neither does the condition seem to be a very rare 
manifestation. 

Partly from my own observations, and partly from the records of 
others, the condition is characterized as follows : pains localized in the 
neck, sometimes in the head also, and especially down the spine, and in- 
creased by movement of these parts. The dizziness -is increased by at- 
tempts at walking, and is nearly allayed by complete repose. There is a 
confused mental condition and a sense of depression ; both of these con- 
ditions struck me as dependent quite as much on the physical condition, 
connected with other organs, as on the cerebral state, strictly speaking. 
These symptoms are continuous, but quickly disappear on the occurrence 
of articular inflammation, which they usually precede. The vertigo may, 
however, alternate with the articular phenomena, and may therefore suc- 
ceed the usual manifestations of the disease, and in turn be followed by 
their reappearance. In a case under my own observation the vertigo, 
with staggering gait, was the initial symptom of a relapse, and ushered in 
an attack of rheumatism affecting the vertebral joints. In this case the 
muscles of the back were becoming strikingly painful, and I was led to 
think that the staggering gait was produced by the failure of these mus- 
cles to properly balance the trunk. The muscular tissue was probably 
involved to a certain degree before the extreme pain was developed in 
them, as occurred later, and this explanation still seems to me not an im- 
probable one. 

So excessive becomes the vertigo in some cases, that the patient falls to 
the ground. Whether this results from a sudden increase of the vertigo 
— the more strictly nervous symptom — or from the disability of the mus- 



150 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

cles, owing to pain, which is present in them in many instances, to a high 
degree, is doubtful. I think from the records of the cases that both of 
these causes may be held accountable for the phenomenon. 

The diagnosis of the condition may be at first very uncertain, and 
great alarm may be caused by the symptom, but fortunately the nature of 
the condition rapidly becomes apparent, usually by the development of 
familiar rheumatic symptoms. The occurrence of the dizzy symptoms, 
intercurrently in an attack of rheumatism, or as a relapse, would readily 
find an explanation, but as primary phenomena they would be quite un- 
certain until the appearance of other symptoms. Occurring in patients 
having a strong tendency to the disease, the rheumatic vertigo could be 
distinguished from a gastric, epileptic, or others of a purely nervous origin, 
or any condition due to grave cerebral lesions. 

The appearance of the vertiginous symptoms may take place in cases 
of very mild, subacute character, or in those of more severe type, and no 
marked tendency to visceral complications of any sort has been shown in 
connection with the recorded cases. Especially is this time in respect to 
endocarditis ; in my own case no valvular murmur existed, although the 
patient had suffered repeated attacks of acute rheumatism, and from a 
previous attack, a year before, pericarditis with adhesions resulted, but 
without endocardial inflammation. 

Cases occur, but only very rarely, in which symptoms very similar to 
those above recorded persist in a chronic manner, accompanied usually 
with vague rheumatic pains in some portion of the body. For example, a 
patient who has suffered from slight rheumatic pain in one or more joints 
becomes affected with dizziness or vertigo, which will persist during the 
whole duration of the slight joint affection ; sometimes the occurrence of 
the vertiginous symptom leads the patient to expect the advent of the 
rheumatic condition, so constantly is the former the forerunner of the 
latter. 

Some of the other forms of manifestation of rheumatism of a nervous 
character are chorea, hysteria, contraction of the extremities, tetanus, in- 
sanity, and some of the visceral neuralgias, so called. 

Conditions which Tend to Produce Cerebral Symptoms and Lesions. 

So far as we are able to extend our observations, we are compelled to 
acknowledge that cerebral symptoms occur in the course of acute rheuma- 
tism without lesions existing in the brain, which we are able to define or 



NERVOUS COMPLICATIONS. 151 

which we can place in correspondence with the clinical features. This is 
true not alone in rheumatism, but also in many acute disorders whose pri- 
mary and principal manifestations are localized in other organs than the 
brain. Yet, although we are unable to point out lesions correspondent 
to the symptoms, we are loath to believe that no lesions exist. 

Hence, it has become usual to account for such symptoms as the effect 
of reflexes. In the case of rheumatism, the efficient reflex has been 
thought to exist in inflammations of the visceral serous membranes, and 
the not uncommon coexistence of rheumatic pericarditis with head-symp- 
toms has been quoted in support of this view. By others the irritative ef- 
fect of a large number of articular phlegmasias is considered as productive 
of the same result. This view is supported by the tendency of head- 
symptoms to appear when a large number of joints are involved in the 
rheumatic process. 

The older authors viewed all cerebral cases as the result of the meta- 
stasis of the inflammation from the joint to the brain, and they accounted 
for the absence of the cerebral inflammatory appearances in the same way 
as the similar disappearance. from the joints themselves. 

Many cerebral cases unquestionably concur with hyperpyrexia, although 
it is not clear which is cause and which is effect. Is the hyperpyrexia 
caused by the localization of the rheumatic process in the brain disturbing 
the heat-regulation of the organism, or are the cerebral symptoms merely 
an incident in the course of a case attended with high temperature ? 

The heart-lesions unquestionably are productive of many cerebral acci- 
dents in acute rheumatism at many stages of its course. The changes in 
this organ, along with alterations in the quality of the blood, cause the 
large majority of all cerebral symptoms, and to these may be added the 
effects of certain remedies which in times past have received credit for a 
greater influence on the cerebral phenomena than at present. 

The frequency, relative and absolute, of cerebral symptoms is modified 
by many circumstances. General statistics show that between three and 
four cases in every hundred exhibit some form of cerebral disturbance ; 
many give higher figures, and some even lower. Certain seasons and par- 
ticular years often furnish large numbers of cerebral cases— larger num- 
bers among an actual fewer number of cases of rheumatism. Men are 
more frequently affected than women, but this results not so much from 
any sexual differences as from their differences in exposure or from their 
habits, especially the use of alcohol. 



152 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The effects of accidental causes, especially exposure to cold, during the 
course of acute rheumatism is seen, from a review of cases, to have 
marked effect in producing cerebral complications. A predisposition to 
nervous phenomena is to be found in rheumatism equally as in other 
acute diseases. 

The period of the attack at which the phenomena make their appear- 
ance varies very greatly. The variety of the cerebral symptom or lesion 
has its effect in determining this epoch. Allusion has been made to the 
primary localization of the rheumatic process in the brain or its membrane 
— those cases in which nervous symptoms are manifested before the ar- 
ticular inflammation — but these instances are exceedingly rare. From the 
fifth to the twentieth day of the attack the largest number of cases are seen, 
but it is necessary to remember that no grade of i-heumatism, mild or se- 
vere as to general symptoms or as to the number of joints involved, shows 
an immunity from cerebral symptoms in one or other of its many diverse 
and distinct forms. Generally, too, they make their appearance without 
definite warning, and are usually rapid in their development, although 
sometimes slow and not unexpected. 

The prognosis in these cases varies manifestly with the efficient cause 
of the occurrence of the nervous symptoms and Avith the severity with 
which this cause is acting. In the majority of cases in all the forms the 
prognosis is unfavorable. 



CHAPTEK XIV. 

MORBID ANATOMY. 

Pathological Changes : Hyperinosis ; Condition of Joints ; Changes in Cartilages ; In 
Tissues and Skin ; In the Blood — Hyperpyrexia — Cardiac Conditions — Endocar- 
ditis — Histological Process in Endocarditis — Embolism — Cardiac Murmur — Val- 
vular Vegetations — Inflammatory Products : 1. Inflammatory Resolution ; 2. In- 
flammatory Organization — Chronic Endocarditis — Pericarditis — Acute and Chronic 
Myocarditis. 

Pathological Changes. 

A description of the pathological changes in rheumatism is necessarily a 
brief one. Partly because in a disease in which the number of deaths is 
small our knowledge is not extended, and partly because the morbid al- 
terations are but few in number. Those that are seen serve to cast but 
little light on the pathology of the malady. 

It is proper in this connection to speak of the mode of death and its 
immediate cause, or the train of symptoms which precede its occurrence. 
And these causes can be classed under various heads, in reference to the 
prominent symptoms which attend them. Thus we see deaths from hy- 
perpyrexia, from cardiac diseases, from pulmonary troubles, from cerebral 
rheumatism, and to these may be added a few others, which are so rare 
that it is not necessary to erect for them special classes. 

It will be seen that all of these, except the first named, are complica- 
tions or localizations of the rheumatic process rather than essential fea- 
tures of the typical disease. Exception may be taken to this statement 
by some who regard the hyperthermic condition as evidence of a nervous 
complication of the malady. This question has already been partly dis- 
cussed, and whatever may be its correct solution, the pathological appear- 
ances so far furnish no evidence by which it can positively be decided. 

Hyperinosis. — Perhaps, in addition to the above given classes, another 
of often striking importance should be mentioned. It is not one, how- 



154 RHEUMATISM, GOUT, AKD ALLIED DISORDERS. 

ever, of which we have symptoms or evidences during life. It is a condi- 
tion which is discovered post-mortem, although in times past it was familiar 
enough when venesection was customarily practised for acute rheumatic 
fever. It is hyperinosis. 

The fever, the blood-changes, and inflammation of the joints — the three 
characteristic and almost essential symptoms or conditions of acute rheu- 
matism — either leave behind them little trace of their presence, or else in 
themselves are not the cause of death. The hyperpyrexia is a frequent 
cause of death, but leaves behind nothing to show its cause and brings 
about only such changes in the organs as we are accustomed to see in 
other diseases attended with high temperature. The blood-changes we 
have but an imperfect knowledge of, and we are almost without a 
knowledge of the essential condition or element which is supposed to be 
present in the blood and to be productive of the rheumatic phenomena. 
The inflammation of the joints, so striking during life, shows, as a rule post- 
mortem, only a little increase of their fluid contents ; even this fluid may 
have almost entirely disappeared, and often none of the other indications of 
a severe inflammation can be detected. 

Condition of Joints. — In describing the morbid alterations found in 
acute rheumatism, the condition of the joints claims our first attention. 
On opening a joint shortly after the epoch of an acute rheumatic inflam- 
mation there can be seen a greater or less degree of injection of the 
synovial vessels, which may in places appear dilated, or even ecchymotic 
spots may be seen. The cavity of the joint contains more than the 
normal amount of the fluid, although its quantity is much less than the 
swelling during the acute stage would lead us to expect. The fluid is 
thinner than the normal synovia and it may be quite transparent, though 
not infrequently it is clouded or quite opaque. A microscopic examina- 
tion shows that the opacity is due to fatty or granular cells, floating in a 
transparent fluid. These cells are derived from the proliferation of the 
synovial tissues. The synovial fringes themselves show a formative 
activity and the cells are seen often becoming detached and separating 
from the basis-tissue. Their substance is highly granular and their nuclei 
enlarged and they stain with great readiness. These cells are seen to 
contain spaces, like vacuoles, which are filled with mucin. 

A chemical examination of this fluid shows that its normal alkaline 
reaction is sometimes changed to acid, but a knowledge of the acidifying 
principle is wanting. No essential difference has been found between the 



MORBID ANATOMY. 155 

fluid removed from the joint during life' and that found post-mortem, if 
we except a condition of coagulation which is sometimes seen to take 
place. And this post-mortem change probably accounts for those cases 
where a fibrinous inflammatory matter has been described. The presence 
of mucin forms the most striking feature of the articular effusion, which 
in other respects closely resembles that found in the pleural cavity as 
the result of inflammation. These fluids contain fibrin, cellular elements, 
and a principle like albumen, which coagulates with heat when rendered 
acid. The fluid in the joints cannot in the strict sense of the word be 
looked upon as ever being purulent, and the opacity which has given rise 
to this notion is conferred by the unusual abundance of the cellular ele- 
ments detaching themselves from the synovial fringes. Suppuration with 
erosion of the cartilages is absolutely one of the rarest phenomena of 
acute rheumatism and probably only occurs in conditions of profound 
dyscrasia. < 

Changes in Cartilages. — Almost the only changes exhibited by the carti- 
lages, at least to the naked eye, are a slight tumefaction, a loss of polish, 
especially noticeable in cases where post-mortem coagulation of fluid takes 
place, and a slight loss of resistance or a softening of their tissue. The 
velvety condition or villosities, which have been described, are probably 
nothing more than post-mortem coagulation of fibrin. The other changes 
in the cartilage which may be present, even when the naked eye appear- 
ances of the tissue are unchanged, consist of hyperplastic and proliferative 
activity, exhibited by the cartilage cells, similar in kind to those seen in 
the synovial fringes. These cells are swollen, the nuclei enlarged, or even 
vesicular and the nucleoli very distinct, and cell-multiplication by division 
has been described as taking place. The changes in the cartilage involve 
principally their superficial layer, and even here only in isolated areas ; the 
deeper portions of the tissue, however, do not escape, but here, as in the 
superficial layers, the change is exhibited in a restricted manner. This 
proliferative activity of the cartilage -cells, if long continued or many times 
repeated, is capable of distorting the regular arrangement of the cells and 
of forming striae which render the superficial layer irregular. The basis 
substance of the cartilage (intercellular substance) is, however, not seen 
to become granular as in scrofulous and other inflammations of the joints, 
although a liquefaction of this part has been described. No deposit of 
adventitious material is ever seen to take place, as is so noticeably the case 
in gout. 



156 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The periarticular tissues, and the skin lose post-mortem to a great 
degree then- characteristic ante-mortem appearances. The redness and 
swelling largely disappear. A certain amount of oedema, however, is dis- 
cerned, and the veins are often turgid with blood. Besides these, in some 
cases subcutaneous ecchymoses are found, and very much more rarely 
trifling collections resembling purulent matter are seen. 

This condition may extend itself to the tendinous bursas, and along the 
intermuscular septa. In these parts, as well as in the periarticular tissues, 
and even within the joints, thickening, resulting in permanent deformities, 
may be found in numerously repeated attacks, though in other cases, after 
quite as frequent repetitions of the disease, almost no alterations are dis- 
coverable. The older authors not infrequently described both acute and 
chronic alterations of the bones and periosteum as the results of rheu- 
matism, but it is probable that the conditions were confounded with other 
diseases of which, at present, we have a better knowledge. 

Changes in the Blood. — The blood, as found post-mortem, is almost al- 
ways firmly coagulated, and its coagulability is shown likewise ante-mortem. 
So great is the increase of fibrin, that acute rheumatism has been described 
as a type of the phlegmasia?. Its amount has been shown to range from 3 
per 1,000, the normal, as high as 6 or even 10 per 1,000. The blood drawn 
during life shows at once the increase of the fibrin, as well as its tendency in 
respect to coagulation, by forming a markedly bufly coat. This same con- 
dition is exemplified by the highly fibrinous character of the inflammatory 
products, seen on the serous membranes, and also in the readiness with 
which vegetations form on the inflamed endocardium, as well as in the 
laminated coagula found in the heart-cavities. The only exceptions 
which are met with where the blood is fluid post-mortem are in some of 
the cases of hyperpyrexia. 

The albumen is often deficient in amount, while the whole amount of 
solids in the serum is increased. The red globules progressively and 
often rapidly decrease in number, the diminution amounting sometimes to 
one-half the whole number. Our knowledge of the other constituents, 
normal or pathological, of the blood is very defective. Urea and uric acid 
have been found in the blood by some observers ; but their presence has 
been denied by others with equal positiveness. Whether lactic acid is 
present or not, the blood serum, except in very rare cases, preserves its 
alkalinity and is certainly uninfluenced by this agent and its presence has 
never been satisfactorily shown. 



MORBID ANATOMY. 157 

Garrod has demonstrated the absence of uric acid or its salts, which 
are universally present in gout. 

In reviewing the records of cases of deai;li from rheumatism it will be 
found that, with the exception of hyperpyrexia, this event results from 
some one of the complications in a very large majority of the number. 
We have just seen that in the one essential symptom of the disease, the 
inflammation of the joints, there are not present conditions incompatible 
with life or that are likely to cause death. We will therefore point out 
the conditions present after death in the various classes of cases. 

Hyperpyrexia. 

The mode of death in these cases is apncea, and the death, as shown by 
the post-mortem condition of the heart and its contents, is not a sudden 
one ; this statement is apparently in contradiction to the clinical record of 
these cases, since the observation is not infrequently made that death 
occurred suddenly. In the majority of them, however, the condition of 
the blood (hyperinosis), favored by the somewhat prolonged agony, gives 
rise to clots of ante-mortem character in the right cavities of the heart, 
which often extend far into the pulmonary arteries. In others of these 
cases unquestionably death is really sudden, and from this and other 
causes the blood is found uncoagulated, though it may clot subsequent to 
its removal from the body on exposure to the air. 

In these cases, as well as in others to which the name of hyperpyrexia 
can scarcely be applied, although likewise attended with high temperatures, 
the post-mortem examination shows very deep congestion of the lungs, 
a congestion which is universal throughout their substance though of 
course more marked at the posterior parts, and therefore due to hypostasis, 
both before and after death. This congestion is promoted by the condi- 
tions above spoken of, both the tendency to pulmonary death and also 
the fibrinous condition of the blood. But it also has a life history and is 
recognizable by clinical features prior to the approach of death. The con- 
gestion seems to attach itself to the general condition of the patient, and 
to be a part of the same condition (or to be caused by it) as the high 
temperature, to be, in other words, of central origin rather than a simple 
pulmonary disease. The respiration is imperfectly performed, because 
through the effects of high temperature the nervous centres do not regu- 
late the respiratory act, or perhaps, so to speak, do not perceive the neces- 



158 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

sity for the aeration of the blood. This description is, I am aware, purely 
theoretical and has no better basis of foundation than the hyperpyretic 
theory itself, except that we know there is a respiratory centre, while we 
do not know of the existence of a heat-regulation centre. 

This congestion of the lung is often so intense that a portion of its 
tissue is deprived of air and it is frequently described as hypostatic pneu- 
monia. Although we find genuine croupous or catarrhal pneumonia occa- 
sionally as a complication of acute rheumatism, this condition is some- 
thing quite apart from inflammation, though doubtless the congestion of 
intense degree has many times been mistaken for the former. The state 
of the lung may be defined as one of splenization, for along with the in- 
tense congestion which lessens the air-space in the vesicles there is also a 
bloody or serous effusion, non-coagulable in character, which completes 
the deaeration of the lung-tissue ; and thus, without collapse and without 
pneumonic consolidation, the lung becomes nearly or quite solid ; the size 
of the organ is often considerably reduced, thus furnishing evidence of the 
failure of respiration. 

It is by no means all of these cases which furnish evidence of failure 
of respiration in connection with hyperpyrexia. In some the lungs are 
not found thus congested, or at least not to a high degree. 

In those cases where the evidence of failure of respiration is absent, it 
is generally noted that both sides of the heart are relaxed and distended 
with blood and not merely the right side. In these cases, therefore, it 
would seem that the nervous failure, if such is really present, affects both 
the respiratory and the cardiac centres and myocardiac ganglia. The 
death in these cases is a more rapid one, and whether from this cause or 
from the changes which take place in the blood coincidently, this fluid is 
found uncoagulated. 

The heart shows evidences of failure — evidences partly derived from 
its relaxed condition, which may be supposed to be nervous in character, 
and partly from microscopic examination showing granular and other de- 
generation of its muscular fibres. 

The spleen is enlarged, smoother looking, and often very much softened, 
so as to be nearly diffluent. If pre-existing cardiac valvular disease with 
vegetations is present, areas of infarction are found in its substance, al- 
though the characteristic appearances of this condition tend to become 
lost in the softening which the organ suffers. 

The kidneys present the characteristic changes of cloudy swelling of 



MORBID ANATOMY. 159 

their tissue. These organs are enlarged, often intensely congested, and 
the microscope shows the renal epithelium swollen and cloudy, although 
the granular condition is not as marked as in the inflammatory changes to 
which these cells are subject. The appearances of the kidneys are of 
course modified according to the existence or absence of prior chronic 
changes or present inflammatory disease. 

The liver shows no characteristic changes, except such as those al- 
ready given for the other organs and which are common to all diseases at- 
tended with prolonged or excessive high temperature. The state of con- 
gestion is in this organ, as in all the other abdominal viscera, especially 
influenced by the mode of death. The gradual failing of the respiration 
renders these organs very full of blood, and this fulness is solely the result 
of the mode of death, and is therefore not explanatory of any save the ter- 
minal symptoms of these cases. 

In addition to these alterations of the internal viscera, the general mus- 
cular system in these cases of hyperpyrexia is nearly always found to 
exhibit changes. The muscular fibres have been described as showing an 
alteration very similar in appearance to waxy degeneration. This change 
has been more frequently described in cases of rheumatism with excessive 
temperature, but it is certainly not absent in certain cases of acute rheu- 
matism in which the fever-heat has not exceeded the usual limit. In typi- 
cal cases of rheumatism alterations of the muscular fibres have not been 
described as having any distinctive characteristics. 

In cases of hyperpyrexia, post mortem decomposition is often devel- 
oped with marked rapidity. 

Cakdiac Conditions. 

It is not my purpose to describe in detail all the appearances of the 
acute changes found in the cardiac apparatus or the conditions which re- 
sult from them due to rheumatic inflammation of these parts. Both these 
and the symptoms and physical signs belong to works on heart disease. It 
will be sufficient to discuss the mode of causation and the results which 
follow from the various forms of cardiac inflammation, since thereby the 
effect of rheumatism in the production of the sum total of heart disease is 
rendered prominent and the seriousness of this complication of the disease 
is constantly held before us. 

The changes which occur in the cardiac apparatus are divided for con- 



160 RHEUMATISM, GOUT. AND ALLIED DISORDERS. 

sideration into three classes, though frequently coming simultaneously, and 
sometimes one the result of the other. They are 1, endocarditis; 2, 
pericarditis ; 3, myocarditis. 



Endocarditis. 

The changes in the endocardium vary in their appearance according to 
the stage of the inflammation, the frequency of its repetition in successive 
rheumatic attacks, and according to the results from degenerative or other 
changes which occur in the inflammatory products. 

In studying rheumatic endocarditis — and it is by far the most frequent 
form of this disease — it is necessary in the first place to try to arrive at 
some notion of the cause of this inflammation or why it is that the endocar- 
dium is affected in this manner. To do this it is necessary to remember 
first that it is the left side of the heart which is affected ; its occurrence 
on the right side of the heart is of the very rarest exception. Secondly 
that the inflammatory changes and their products are seen to be confined 
to an exceedingly restricted area of the lining membrane, viz., the line of 
contact of the valvular leaflets. 

The reasons which have been given for the involvement of the endocar- 
dium have been very various. The older metastatic notions of the disease 
can, I think, be at once put to one side. By others, the occurrence of the 
inflammation has been traced to the direct contact of the blood bathing 
the surface, bearing in its current the irritant rheumatic material, and the 
fact that the inflammation was limited to the left side of the heart, has 
been explained by the physiological difference in the blood before and 
after its passage through the lungs. 

In answer to this it seems quite enough to say that the interiors as 
well as the surfaces of other organs find quite as intimate contact with the 
irritating material as does the endocardium, and so far as any physiologi- 
cal — or in this case pathological, since we are dealing with a foreign mat- 
ter in the blood — difference is in question, it is purely speculative and no 
facts in support of the theory have been furnished. 

To arrive at the cause, and to state it in exact terms, of the endocardial 
inflammation, we are quite as much at a loss as to account for the articular 
inflammation, but it seems from every point of view that we are justified 
in looking at the cause as the same, and that the cardiac inflammation is 
not in any sense a transference of the disease from the joints. This seems 



MORBID ANATOMY. 1G1 

to be clearly shown by the unquestioned occurrence of endocardial in- 
flammation prior to the articular mischief. It would seem, therefore, that 
we are justified in regarding the rheumatic process as a general one, 
which may manifest itself by symptoms at one point of the organism at 
one time, and at another point of the organism at another. The rheu- 
matic process is going on all over the organism on each occasion of an 
acute paroxysm, and we are no more bound to show why a cardiac compli- 
cation occurs in some cases and not in others than we are bound to show 
why it occurs in the knee-joints in a given case and not in the elbows. I 
think, however, though not logically called upon to do so, that we can in 
certain instances show the reason of the cardiac complication, and per- 
haps also show why one joint is more frequently affected than another. 

The point which I wish to insist upon is, that during the course of the 
rheumatic process the whole body is affected, but through certain accidental 
circumstances only certain parts are influenced, or that certain results are 
brought about in them which give rise to the symptoms that point out 
what we speak of as a rheumatic complication. 

I would suggest, in confirmation of this view, what we see in any large 
series of rheumatic cases. In some cases, which apparently differ in no 
respect from others, we see the occurrence of skin eruptions, in others 
nodosities form, in others rheumatic oedema, and in all of these we see 
but different manifestations of the rheumatic process affecting the dermic 
or subcutaneous connective tissues. 

While the process is thus a general one, and probably affects all parts 
of the organism, one sort of tissue seems to be, according to the history 
of the rheumatic symptoms, much more generally, if we are not able to 
say solely, affected than the others. This tissue is the connective-tissue 
group. It is usually said that the fibrous tissues are the ones affected 
chiefly, but I think that the more general statement is better calculated to 
include all the facts which are witnessed. The connective-tissue group is 
inclusive of all the fibrous tissues, and includes all those tissues and 
organs which make up the intermediary nutritive apparatus. 

This group, therefore, comprises all parts of the organism which func- 
tion to move the body as a whole, which move individually, and are es- 
pecially influenced by pressure in general, as well as in local move- 
ments. It includes, therefore, all the general locomotive apparatus, the 
circulatory organs, and the interstitial connective tissues, especially such 

as form the boundaries of the great serous cavities. It excludes the epi- 
11 



162 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

thelial-clad surfaces and the epithelioid organs, commonly spoken of as 
the solid viscera ; and probably also excludes the greater part of the con- 
nective tissues, so called, forming the internal skeleton or framework on 
which rest the epithelioid elements of these organs. 

It will be seen that the rheumatic complications manifest themselves 
almost entirely in this tissue group. And it would seem that the fre- 
quency of the rheumatic manifestations in one part rather than in another 
was in some degree proportional to the normal functional activity or an 
activity brought about by pathological conditions. 

I therefore would affirm the view that in every rheumatic attack, the 
more acute and the more profound the affection the more markedly does 
it occur that the cardiac tissues — and of course with them all the other 
tissues of the connective -tissue group — are affected by the blood-changes 
which the rheumatic process is capable of bringing about. This state- 
ment does not carry with it the affirmation that in every case of acute 
rheumatism we must necessarily have cardiac lesions. The lesions in the 
heart come as do those in any single one of the many joints, probably as 
the result of functional activity having been greater in one articulation 
than another during the state of health, or in the case of the heart or 
other internal organ the functional activity has been increased by patho- 
logical conditions. 

"We can hardly escape the conclusion that in a general disease like 
rheumatism every part of the body is affected by the blood-changes, and 
that the special localizations or lesions which result from this general con- 
dition are predisposed to such localizations through the greater activity 
of the circulation, induced by an increased function, normal or pathologi- 
cal. "We are not by any means able to point our finger directly to the 
kind or the occasion of such increased function, but this is probably the 
nearest we are able to arrive at an explanation of the phenomena witnessed 
and it appears withal satisfactory. The joints most commonly affected are 
those which in any given individual seem to be, from the nature of their 
occupation, the most used. And in the case of the heart-valve, how 
frequent it is to find, after any hurrying of the circulation, caused by ex- 
ertion or excitement, a valvular murmur developed at the mitral orifice. 

In accordance with these views we are able to indicate the reasonable- 
ness of the occurrence of endocardial changes of the left side of the heart, 
for it is this side which does the most work, and consequently its valves 
have a greater strain to bear. 



MORBID ANATOMY. 163 

That the acute endocardial changes are limited to such an exceedingly 
restricted area of the valve likewise finds a ready explanation. No one 
could possibly suppose that in a general disease like rheumatism the 
inflammation of the valvular tissue would be developed only at the line of 
contact of the opposed leaflets, an area so restricted that unless the 
changes are well advanced they may wholly escape detection. 

We must suppose that the whole leaflet is affected by the rheumatic 
process and that for some reason the roughening which we accept as evi- 
dence of an inflammation is brought about by some accidental circumstance 
which does not influence the whole leaflet. This circumstance we find in 
the fact that the swollen, softened valve beats against its opposing fellow 
only along the line of contact where we find it roughened. The softened 
tissues hammer themselves against each other at, it may be, double the 
normal frequency, and are pressed upon in closing the valvular orifice by 
blood at more than the normal tension, and thus with great frequency 
become roughened along the points where they meet. Once roughened 
they gather up the fibrin from the blood, more highly charged with this 
ingredient than normally. And when this has occurred the condition is 
arrived at which notifies the ear placed over the heart that a cardiac lesion 
has occurred. 

I believe that in all cases when the rheumatic process is developed with 
sufficient profoundness to be distinctly recognized, the cardiac tissues and 
especially the valvular apparatus is affected to a greater or less degree by 
swelling and consequent softening, which in these non-vascular tissues we 
hold to be expressive of inflammation. A valve under these circumstances 
does not necessarily become roughened, or even if roughened may not 
collect fibrin on its surface, owing to a less fibrinous condition of the blood, 
but we can readily see how a valve may thus become damaged if any ex- 
citement of the circulation takes place, and can also understand that some 
valves are more resistant and less likely to be roughened than others. 

If, then, we take into consideration all these facts — that some valves 
are less softened, that less fibrin is present, and that some are more re- 
sistant than others, and also that in some cases a given quantity of rheu- 
matic material in the blood produces more softening of the valvular tissues 
in some cases than in others — we have I think a more reasonable explana- 
tion why some cases are affected by valvular lesions when others of equal 
severity escape, than by supposing, as is generally done, that in one case 
the heart is affected by the rheumatic process and in the other is wholly 



164 

unaffected. Its tissues are affected in all cases, and for the reasons above 
given lesions manifest themselves in one case and not in another. 

This view will help us to explain many cases of valvular disease of the 
heart, both those which can be recognized clinically, and many more also 
which we know of for the first time post-mortem. If we can believe that 
the delicate valvular tissues are affected in all cases of rheumatism, but in 
only the minority give us physical signs during or shortly after the acute 
paroxysm, we shall be able to explain those other cases of valvular alter- 
ations, many of them of very slight character, above referred to, found 
in persons who have suffered rheumatism but who during the acute or 
subacute conditions furnish no evidence of cardiac valvular disease. In 
such cases it is easy to suppose that the rheumatic process affected the 
valves, but only after a long period of evolution, that the rheumatic in- 
flammation brought about valvular changes sufficient in degree to give rise 
to physical signs or symptoms, or the effects remaining quiescent merely 
show the alterations which we recognize at the post-mortem. 

Histological Process in Endocarditis. 

Minute examination of a cardiac valve in acute endocarditis gives us 
the following appearances, provided the valve is in a normal state prior 
to the inflammation. With the naked eye an injection of the capillaries 
cannot be made out, since these vessels are by far too scanty and widely 
separated in the tissue to show this appearance, common to all inflamma- 
tory conditions. Microscopically, however, it can be seen that they do 
participate in the change, since along their course nuclei are seen in in- 
creased numbers and those of the vessel- walls swell in dimensions. The 
presence of increased blood-supply and a condition of injection can be 
made out when the endocardial lining of the ventricle shares in the in- 
flammatory condition, but this appearance is never conspicuous, because 
the reddish network has for a background the muscular tissue of nearly 
the same color. 

I have seen a very slight pinkish hue in an inflamed leaflet, but this 
color can never be accepted as an evidence of inflammation, because of the 
liability of valves to be stained red by the blood-coloring matters. There 
seems to be less likelihood of this occurrence in acute rheumatism, however, 
than in most other acute febrile diseases, since in the former the condition 
of the blood is not such as to produce staining. 



MOREID ANATOMY. 165 

The absence of a capillary supply to the valves has caused some obser- 
vers to deny the occurrence of inflammation in their tissue, but quite un- 
warrantably, since if a vascular nutrition is maintained surely a similar 
sort of inflammation can find place. 

The increased blood-supply causes a swelling of the valvular tissue by 
the presence of the serous fluid in its meshes. This swelling loosens up 
the meshwork of the fibrous tissue and disassociates its fibres. The inter- 
stices of the tissue are filled not only with serum but with cellular ele- 
ments, both those of a wandering character and those derived from the 
proliferation of pre-existing cellular elements. The swollen valve is thus 
rendered not only opaque, but also becomes softened. It is well to note 
just here, that the histological evidence is in favor — nay, distinctly shows 
that this inflammation is, so far as the valve is concerned, an internal one, 
not external. The change commences in its deeper parts, not on the sur- 
face, and therefore it is caused by alteration in the circulation of the part, 
and not by the blood flowing past the inflaming area. 

The softening of the tissue and the cellular proliferation quickly affects 
the superfical or peripheral layers. The valve, thus thoroughly softened, 
shows unequal thickening, or prominences more marked at some parts than 
others, corresponding to and caused by aggregations of the fluid or cellular 
elements. The valve, though showing low elevations at points, is until 
now smooth, but from the softened condition of its tissues is liable 
at any moment to become roughened by abrasion of its surface along the 
line of contact of the opposing segments of the valves, or, if the softening 
of its tissue is more thorough-going, by a laceration or perforation of the 
leaflets. 

This roughening when only a superficial abrasion, is not sufficient in 
itself to give rise to a valvular murmur. The perforation or laceration of 
the valve, a very much more rare event, does of course cause murmurs, 
which are rapidly produced and are usually harsh in character, or even 
double in the time of their production. I say that the superficial abrasion 
of itself does not produce a murmur, and the same is apparently true of 
the unequal elevations or inequalities of the valve even when they occur 
at the line of contact. Self- evidently, microscopic abrasion does not pre- 
sent a surface sufficiently uneven to give rise to a sound by the blood 
passing over it, and the inequalities, even those at the line of contact, 
since they are in their early stages so soft in character, do not prevent the 
complete closure of the valvular orifice, and hence, as they allow no regur- 



166 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

gitation, give rise to no murmur. The soft tissue, although uneven, moulds 
itself to meet closely the opposing leaflet, and manifestly it is not rough 
enough to cause a sound as the direct current of blood flows over it. These 
inequalities, at first soft in character, if they ever produce murmurs must 
be very large in size, and we rarely ever see such and have little reason to 
believe they ever exist. Later they may become firmer and, rendering 
the valve stiffer than normal, prevent a complete closure, and thus allow 
of regurgitation. 

These softened valves do, however, change the cardiac valvular sounds 
from the normal, and these sounds, so far as they are due to the clashing 
of the leaflets, are rendered softer, less distinct than normal. This change 
is often spoken of as muffling, and is due to impact of the softened leaflet 
as compared to that of the normal firm fibrous tissue. The alteration of 
sound is frequently noticed during the course of acute rheumatism, even 
when no distinct murmurs occur, and I have thought that it was present 
in cases of other acute febrile diseases, in all of which parenchymatous 
changes pervade the organs. Muffling is, however, produced by other 
causes than that here alluded to. 

The next step in the rheumatic endocardial inflammation must, I think, 
be regarded as the principal, at all events the most frequently occurring 
one in the production of acute cardiac murmurs. It is the deposit of 
fibrin on the surface of the valves. We have seen that the very slight 
roughening of these structures, taking place almost if not solely along their 
line of contact, is not sufficient to produce a murmur, but this roughness 
is especially favorable, nay essential as a starting-point for the adhesion of 
the fibrin. The fibrinous deposit does not form on the smooth endocar- 
dial surface ; roughness is essential to form its clinging spot. The rough- 
ening, though not evident to the unaided senses, and though only micro- 
scopic in character, almost necessarily, in the hyperinotic condition of the 
rheumatic blood, begins a fibrinous accretion. The fibrinous deposits are 
the vegetations of acute endocarditis. These vegetations form the warty 
or beaded excrescences on the valves along their line of junction, and at all 
other parts of the surface where roughening takes place, though this latter 
rarely occurs. 

This fibrinous deposit is firm, or becomes firm in character very rapidly, 
and just so far stiffens the border or line of contact of the valve. It cannot 
be said in this early stage of the process to render the valve rigid, still, 
after the fibrin is deposited, the surface of the structure is no longer soft 



MORBID ANATOMY. 1G7 

and easily conformable to other inequalities presented by the opposing 
leaflet. The closure of the orifice at which they form is incomplete by just 
the number and size of the vegetations present. After the fibrinous de- 
posits take place, the opposing surfaces of the leaflets no longer meet as 
do the soft fleshy parts of one's two hands when pressed together, but like 
the knuckles when opposed to each other. The interstices between the 
opposed rounded prominences of the vegetations allow of a regurgitation of 
blood, and a soft, not very loud murmur is heard at the point of greatest 
intensity, the sound corresponding to the valve at which the change is 
present. Rarely are the vegetations sufficiently large to produce a sound 
by the blood flowing over them in its onward course ; the murmur is usu- 
ally a regurgitant one. 

These vegetations form a much more conspicuous feature in endocar- 
dial inflammation than the changes in the valve which are the direct cause 
of their existence, but even the deposits themselves require a careful 
scrutiny to detect their presence, and unless one has a familiar acquaint- 
ance with the normal structure, the inflammatory changes in the valve niay 
be readily overlooked. The vegetations on the valve serve to direct atten- 
tion to the softening of its tissue and to indicate that the opacity of its 
tissue is due to a recent active condition, and is not the result of past 
changes. 

The vegetations are pretty firmly attached to the valve, and are usually 
not easily brushed away, though they may be obscured or covered over by 
clots even of a fibrinous character, though usually soft, which have formed 
in or extended through the valvular opening during the death agony, or T?y- 
those of post-mortem formation. These clots when washed away or care- 
fully removed reveal the vegetations beneath them seated on the surface 
of the valve. 

Taking into consideration the cause, the character, and the circum- 
stances of the formation of the fibrinous deposits, and the softened state 
of the valve and the abrasion which its surface has suffered, I do not think 
we can regard the vegetations in acute endocarditis as, other than protect- 
ive in their effect, so far as concerns the valve itself. The results which 
follow from these deposits to the valve, to the heart, and to other organs 
of the body, as well as the dangers which they bring with them, require 
separate consideration. 

Let us consider their immediate effect, their office, so to speak, in re^ 
lation to the valve. The softened valves are abraded by pounding them- 



168 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

selves against each other at a higher rate of speed than normal. Their 
roughened surfaces collect fibrin which soon becomes hard, firmer at least 
than the softened valvular tissue. Could any device be found better able 
to shield the inflamed valve and prevent laceration or perforation ? and 
we have every reason to believe that the fibrinous deposits do thus protect 
the valves from serious accidents, but on the other hand, their formation 
may, and generally is attended later on with results which are but too 
constantly disastrous. 

Embousm. 

Among the earlier occurring disastrous results, we cannot enumerate 
embolism as among the more common, although when it does occur the 
embolic masses give rise to the most striking symptoms. Embolism is 
much more frequent during the inter-rheumatic periods, or from a sec- 
ond attack of endocardial inflammation taking place in a previously de- 
formed valve, and this condition will be discussed under chronic endocar- 
ditis. 

Cardiac Murmur. 

The immediate clinical effect of the formation of the vegetations is the 
production of a cardiac valvular murmur, but, as we have seen in describ- 
ing the symptoms of cardiac complications, the endocarditis and the val- 
vular insufficiency come on often imperceptibly, and are known by the 
physical signs rather than from any change in the general conditions of 
the patient. The occurrence of the murmur, and therefore of the endo- 
carditis, is almost without perceptible effect on the heart as a circulatory 
organ, and almost equally so on the course of the acute affection. 

"We must look, therefore, to the morbid histological process taking 
place in the valve to learn the cause of the later- coming disastrous re- 
sults. We have seen an inflammatory process going on in the fibrous 
tissue of the valve, attended with the proliferation of cellular and other 
inflammatory products, and that this process finally extended to the su- 
perficial layers of this structure. We cannot but believe that an exuda- 
tion of these products takes place on the surface of the valve, yet except 
under certain conditions, to be spoken of later, we never see these materials 
on. the. surface. 



MOEBID ANATOMY. 169 

They are washed away by the blood-current as soon as they are free 
from the tissue. They are derived from the blood and return to it, be- 
coming mingled with its mass and unrecognizable in it. They seem to 
give rise to no symptoms or changes in tissue which have as yet been 
clearly pointed out. Possibly, however, they may in certain cases give rise 
to those multiple cutaneous emboli which are occasionally seen occurring 
in rare cases before we recognize the existence of cardiac valvular mur- 
murs. It may be to this condition of affairs that Hueter refers in express- 
ing his views of the pathology of rheumatism. 

"When, however, the vegetations form on the border of the valve — and 
it is at this part that the evidences of inflammation are always the most 
marked, since the mechanical irritation is here superadded to the rheu- 
matic process — the inflammatory exudation is retained under the fibrinous 
crust, and the products tend to increase the swelling and thickness of the 
valve at this part. A vertical section made through the leaflet, including 
its free border and its line of contact covered with the fibrinous deposit, 
shows the demarcation between the fibrin and the exudative products, 
and also that at this covered spot of the valvular section the exudative 
products are more abundant than at other parts. The distinction between 
the overlying fibrin and the retained inflammatory material has not been 
always accurately made. Microscopically the difference in their appear- 
ance is well marked, the fibrin appearing stratified, from its deposition in 
layers, while the products derived from the inflamed valve show as highly 
granular material and often with numerous nuclei or cellular elements im- 
bedded in it. The granular condition often extends into the contiguous 
layers of fibrin to a slight degree, but not sufficiently to produce any con- 
fusion as to the actual boundaries of the two materials. I have described 
the inflammation as being confined to the part beneath the layer of fibrin, 
but I do not wish to convey the idea that these products are placed out- 
side the proper tissue of the valve, forming a layer or bed of itself super- 
imposed on the valvular tissue. It is more correct to think of them as 
seated within the valvular tissue, but coming to the surface and in contact 
with the fibrin through the abrasion of the superficial lamella of the valve. 
From the point of abrasion of the valve we see the inflammatory products 
diffusing themselves in a progressively less and less abundant quantity as 
we retreat from this point as a centre. 



170 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Valvular Vegetations. 

However much opinion may differ as to the histological nature or ori- 
gin of the vegetations found on the surface of the valve, none can exist as 
to the course followed by both these products and inflammatory materials 
deposited in the valvular tissue. 

Of the vegetations, we can say with certainty that they pretty promptly, 
in typical cases, organize and fuse with the valve and become a part of it. 
In favorable cases when the inflammation subsides with the acute par- 
oxysm, or even during its course, the fibrinous deposits smooth off the 
surface toward the blood-current and also contract in size, and thence the 
murmurs to which they gave rise progressively diminish and often rapidly 
so. Judged clinically, it would seem that in some cases — and apparently 
not a few in number — the formation of this layer of fibrin, deposited from 
the blood, acts, when it is small in amount and is rapidly organized, like 
an adhesive inflammation in stopping the friction- sounds of pleurisy. In 
neither case does the inflammatory process absolutely cease, though some 
of the untoward tendencies are dissipated by the event. 

In unfavorable cases the deposition of fibrin becomes exaggerated, the 
inflammation does not subside, the softening and swelling of the valve 
continues, and above all the fibrin fails to consolidate and to become or- 
ganized. Under these circumstances, so far as concerns the fibrinous 
deposit, portions of it may be separated and washed off in the blood-cur- 
rent, giving rise to infarctions. The portions which adhere to the valve 
may by their great size cause marked insufficiency of the orifice or form a 
considerable obstruction, in either case producing disturbance in the on- 
ward movement of the blood. Again, the adhering fibrin may, flapping- 
backward and forward with movement of the valve, abrade the sur- 
rounding parts of valvular endocardium as well as such portions of that 
lining the cavities as are within its sweep. Thus new centres of endocar- 
dial inflammation and roughening are established, which in turn give rise 
to new fibrinous deposits with a collection of inflammatory material in the 
subjacent tissue. These latter class of changes are by far more frequent 
in chronic endocarditis or in acute changes occurring in a damaged valve 
than in primary acute inflammation even of the greatest severity, although 
we cannot exclude them from among the possibilities of primary acute rheu- 
matism with endocarditis. Finally, adhesions may also take place between 
the fibrinous masses, and fusion of the portions of the leaflets result. 



MORBID ANATOMY. 171 



Inflammatory Products. 



The course pursued by the inflammatory products in the valvular tis- 
sue varies with the severity and the duration of the inflammation, and can 
be classed under the usual changes which all inflammatory products un- 
dergo in the process of recovery. 

1. Inflammatory Resolution. — We can describe a distinctive resolution 
of the inflammation. Such cases as those spoken of above as resulting 
favorably are here to be included, and also those in which we may believe 
an inflammation occurs in the valve without a valvular murmur being 
heard to attest its existence. The resolution — the abortion of the in- 
flammation — may be more or less complete, and in proportion to its com- 
pleteness does the inflamed part return to normal conditions. With the 
abortion of the inflammatory process the newly formed or emigrating cel- 
lular elements are removed. No new connective or fibrous tissue is laid 
down and no cicatricial thickening or contraction is brought about. The 
pre-existing permanent connective-cells of the valve are necessarily in- 
fluenced and will invariably show alterations, but these changes may be 
completely effaced by time in the most favorable instances. These cases 
furnish, therefore, a group, in which, after a substantial inflammation has 
existed, a return to the normal is effected ; this normality may be com- 
plete anatomically, and in very many more cases is complete functionally, 
though not anatomically. How numerous such cases are we have no 
means of determining absolutely, partly because the criteria of the exist- 
ence of the inflammation are imperfect and partly from the rarity of post- 
mortem inspection. But judged of clinically, it is within the experience 
of all, that cases of rheumatic endocarditis recover, become free from mur- 
mur, and never subsequently have cardiac symptoms. Post-mortem evi- 
dence is not wanting of cases of valvular inflammation which, dying of 
other disease in subsequent years, show altered valves which are function- 
ally normal. 

2. Inflammatory Organization. — In all cases of endocarditis in which the 
inflammatory materials become abundant and are present for any length 
of time, organization of the inflammatory process takes place. The new 
cellular elements lay the foundation of new fibres, and the original tissue 
suffers a hyperplastic increase. The permanency of this increased tissue, 
thickening the valve, is assured through the development of new capil- 
laries or the extension and enlargement of the old vascular apparatus. 



172 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Tlie embryonal or rounded cellular elements become by complete organ- 
ization a cicatricial tissue, and added to this we have the thickening of the 
valve by the hyperplasia of the original tissue of the part. The contrac- 
tion or deformity of the leaflets of the valve depends primarily on the de- 
velopment of the new elements, while its bulk may be augmented through 
simple increase of the old tissues, without cicatricial retraction manifest- 
ing itself ; of course the cicatricial tissues themselves still further augment 
the mere bulk of any affected valve. 

The changes in form which the valvular orifice and the leaflets of valve 
undergo depend in great degree on the position in the valvular tissue in 
which the inflammatory cicatricial material is placed, and on the subse- 
quent changes, constructive or degenerative, which the tissue suffers. 
The forms which the orifice and leaflets assume under these influences are 
legion, and the actual changes, beyond the mere facts ascertained by the 
physical signs or symptoms, of valvular insufficiency cannot be predicted 
clinically. Their description belongs to the study of cardiac disease and 
the work of the pathological anatomist. 

Chronic Endocarditis. 

Besides the acute endocardial inflammation and the changes which 
progressively result from it, there occurs an inflammation which can only 
be described as chronic throughout its course, which is likewise very 
potent in altering the forms of the valves and entailing the mischievous 
consequences of cardiac valvular disease. It, like the acute form, is by 
far more frequent in the valves, though its frequency at other parts of the 
endocardium very far exceeds the acute manifestation at these parts. 

The chronic endocarditis is described as a process essentially inflamma- 
tory, though wanting in certain steps and chronic throughout its whole 
course. It has its analogue in the chronic endo-arteritis or atheroma with 
which we are so familiar. When describing a process as chronic, a cer- 
tain amount of doubt must rest on its history, since by no possibility can 
we see its early stages, and this is especially true of chronic endocarditis. 
"We know of the possibility of its commencement by an acute process so 
slight in its inception that from the vague criteria by which we judge of 
its occurrence it passed unrecognized. Then, too, the distinction between 
chronic and acute is one of quantity and rapidity rather than of duration. 
In speaking of chronic endocarditis we must remember that the acute 



MOKBID ANATOMY. 173 

process may, as the result of a "slowing up" in its rate of progress and 
certain transformation of the products, present us with the essential con- 
ditions to which we give the title of chronic endocarditis. 

The induration and the deposit of lime salts are to be looked upon as 
characteristic features of the chronic process, but these are not wanting 
in the transformations or retrograde degenerations which are exhibited in 
terminal stages of inflammations which we know to have been acute during 
a part of their course. Our knowledge of chronic endocarditis succeeding 
the acute form as the result of acute rheumatism is, however, pretty 
complete. The thickened, the contracted, and the deformed valves nearly 
always show evidences of chronic inflammation, if, in fact, their condition is 
not entirely produced through this slow process succeeding an acute 
disease, and the valves in this state are peculiarly liable to exhibit acute 
inflammation on the recurrence of acute or subacute paroxysms of rheu- 
matism. 

The insufficiency of a valvular orifice — the obstruction or regurgitation 
of the blood — is not alone determined by the altered form of the leaflet, 
but is conditioned also by the fibrinous deposits which are more or less 
continuously forming on the roughened surfaces ; a valve which, although 
thickened or stiffened, is still capable of completely guarding the orifice 
is rendered insufficient through a collection of vegetations on its surface. 

Pericaeditis. 

The appearances presented by this serous membrane when inflamed 
in the course of an acute rheumatism show no substantial difference 
from those produced by inflammations owning other causes. It has been 
thought by many observers that the fibrinous character of the lymph is 
more marked in the rheumatic cases than in others, and this observation 
is to a certain extent true, whatever may be its explanation. But certainly 
a considerable number of cases are seen of what may be considered as 
idiopathic pericarditis, in which the lymph is quite as abundant as in the 
most marked rheumatic cases. In the Bright's disease, or uremic form of 
the inflammation, the lymph is much less abundant than in the rheumatic 
form, but the explanation of this difference rests on the shorter duration 
of the process in the former than the latter. The pericarditis of contracted 
kidney is usually seen as one of the terminal phenomena of that disease, 
and lasting but a short time just previous to death, and hence less likely, 



17-4 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

other things being equal, to develop large quantities of the inflammatory 
products. 

The rheumatic complication of this malady frequently terminates in 
general or partial adhesions, and it has been thought that many of the 
white patches seen on the surface of the heart or the sac walls are the 
result of localized inflammatory changes of short duration in the course of 
rheumatic attacks. These latter are certainly seen with great frequency 
in patients who have suffered from rheumatism. 

Acute and Chronic Myocarditis. 

Inflammatory conditions of the muscular substance of the heart are 
nearly always seen accompanying inflammation of both the lining mem- 
brane and the pericardium. It is invariably present to a greater or less 
extent in the latter, but is not common in a noticeable degree in the 
former, except when the lining of the cavities is involved in the disease ; 
when endocarditis is centred on the valvular tissue naturally we would not 
expect to find a coincident inflammation of the muscular tissue. • 

Myocarditis then, as we see it in rheumatism, is generally the result of 
an extension of the inflammation from the lining or the covering of the 
heart. Of its appearances or symptoms as a primary disease of the car- 
diac muscle we know almost nothing. In fact, if we transfer the phenom- 
ena seen in muscular rheumatism to a similar affection in the heart, we can 
readily believe that even the initial period of the disease is incompatible 
with life. 

A state of hypereemia of the tissue, and even some slight degree of 
cloudy swelling of the muscular fibres, has been described in those rapidly 
fatal cases of hyperpyrexia, and these conditions 'have been pointed to as 
instances of acute myocarditis. The irritability of the heart and the pain 
and some other symptoms seen in certain cases and not in others of endo- 
carditis, and seen in pericarditis, have been explained in a similar manner. 
The palpitations which occur unconnected with the usual inflammations of 
the heart, likewise have been thought to be due to similar conditions seen 
in the peripheral muscles, though not necessarily in either case regarded 
as inflammatory in character. But of any of these states, we have little or 
no knowledge from post-mortem evidence to guide us to a correct conclu- 
sion. 

Acute and chronic changes of the muscular tissue are seen in both 



MORBID ANATOMY. 175 

acute and chronic endo- and peri-carditis. The inflammation of the sur- 
faces extends to the intermuscular fibrillar connective tissue in which its 
effects are principally exhibited. In the acute condition of the endocardial 
form of the disease the earlier stages correspond with acute endocarditis, 
but with its immediate effects on the muscular tissue in this situation w r e 
know little more than the results. In the favorable cases beneath the 
thickened endocardium of the ventricular surface we find the subendocar- 
dial tissues thickened, and if this condition extends far below the surface 
the muscular fibres are missing. In other rare cases a process which can 
only be described as ulceration occurs. A true melting down of the mus- 
cular fibres takes place, and the surrounding tissues are found infiltrated 
with inflammatory products and purulent matter. In other somewhat 
similar cases, instead of the ulcerative excavation, a large fungous out- 
growth results from the deposits of fibrin, but the subendocardial tissue 
and the muscular fibres show the effects of the inflammatory process. 

Another effect of myocarditis of rheumatic origin is the indurative 
change which is not infrequently exhibited. This change is certainly a 
chronic one in its course, and is found as a diffuse and also as a local pro- 
cess. It occurs as the result of the extension to the muscular tissue of 
both endo- and peri-cardial inflammation, though it is also found with any 
exhibition of the effects of either disease. 



CHAPTER XV. 

DIAGNOSIS AND PROGNOSIS. 

Diagnosis : Pyaemia ; Gonorrhoeal Rheumatism ; Acute Rheumatoid Arthritis ; Acute 
Gout ; Pain ; Age : Duration of Attack — Prognosis — Death from Violence of the 
Fever ; Death from Cardiac or other Visceral Complications ; Disability from 
Joint Changes ; Liability to Second or Recurring Attacks, or to Chronic Rheuma- 
tism—Predisposition to the Disease. 

Diagnosis. 

The diagnosis of the nature of a well-developed attack of rheumatism or 
rheumatic fever presents but little or no difficulty, and there are few mal- 
adies with which it can be confounded. The existence of fever of greater 
or less degree, with pain localized in or about one or more of the larger 
joints, with swelling, redness, and tenderness of these articulations, taken 
in connection with the history of the patient, can hardly fail to indicate to 
every one the occurrence of a rheumatic attack. 

In the subacute and mild cases of rheumatism, and those in which the 
manifestations of the disease are limited to particular organs or localities 
the recognition of the disease often presents great difficulties, which, at 
the beginning of such attacks, baffle diagnosis. In fact, it is just such 
cases which, from the abseuce of a certain means of recognition, are the 
cause of much of the confusion in relation to the cause, pathology, and 
treatment of the rheumatic affections in general, and compels, perhaps 
much less at present than formerly, the classification under one head of 
many dissimilar diseases, or at least diseases which, having in common 
the phenomena of pain or the symptoms, owe their occurrence to quite 
unlike causes or morbific agents. In respect to chronic rheumatism — of 
whose differentiation from other chronic muscular and articular affections 
more in detail will be given subsequently — this confusion is perhaps even 
greater than in cases of the milder forms of the acute type. As has al- 
ready been remarked, the dissimilarity of the chronic from the acute type 



DIAGNOSIS AND PROGNOSIS. 1 < ( 

is so great that many have been led to disassociate the two forms of dis- 
ease, as owning different pathological causes. 

Speaking first of the diseases which may possibly be confounded with 
acute rheumatism or rheumatic fever, there are to be mentioned, pyaemia, 
gonorrhceal rheumatism, acute rheumatoid arthritis, acute gout, acute 
synovitis, puerperal synovitis, glanders, milk leg, trichinosis. 

Of these, however, there are only a few in which even the most super- 
ficial observer would overlook the manifest distinguishing points of differ- 
ence. The three diseases, first mentioned above, which belong to the 
arthritic group, will be spoken of later, and their diagnostic features given. 
An acute synovitis, due to prolonged exposure to cold or to traumatism, 
may resemble acute articular rheumatism in the phenomena connected 
with the joint, the tumefaction and tenderness being the same, but in all 
the other symptoms, except perhaps fever, the two diseases widely differ. 
In trichinosis, the confusion between severe acute muscular rheumatism 
and the muscular pains and irritation due to the invasion of the parasite, 
might possibly exist at the beginning, but the subsequent symptoms be- 
longing respectively to the two diseases would soon settle the question. 

Milk leg is easily to be distinguished from the history of the case, as 
it occurs usually in pregnant women, or shortly after delivery, or after 
some continued fever, and a puerperal synovitis may be distinguished by 
the same means. 

Pycemia. — Although pyaemia has an irregular febrile type, like acute 
rheumatism, the presence of an external injury, or more rarely of internal 
lesions, at once points out the difference. In addition, the chills in pyaemia 
are usually much more conspicuous, severe, and frequently repeated, at 
least this is so by the time the disease has advanced to a stage when many 
joints are involved. In other cases, where few or none of the articulations 
are involved, no difficulty arises in distinguishing the malady from one of 
rheumatism. The non-acid character of pyaemic perspiration will almost 
invariably differentiate the two conditions. Death, preceded by typhoidal 
conditions, rapidly solves all doubts, which can exist only at the very 
onset of a pyaemic disease. 

Gonorrhceal Rheumatism. — In gonorrhceal rheumatism, the presence of 

the specific discharge will almost certainly lead to a correct differentiation 

of the conditions. Although usually the course of this form of rheumatism 

alone will enable us to reach a correct conclusion, yet without a positive 

history of gonorrhoea, we may for a time remain baffled. And it is sur- 
12 



17S RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

prising how often it is nearly or quite impossible to obtain a correct his- 
tory. I have known men who, apparently with all sincerity, were unaware 
of their condition until the actual voiding of drops of purulent matter 
from their urethra demonstrated to them the existence of a specific dis- 
ease—men who, without a particle of desire to conceal their condition, 
recognized the meaning of the urethritis from previous personal acquaint- 
ance with its symptoms, but could with difficulty recall the occasion of 
their exposure, which, not unfrequently, had taken place during alcoholic 
intoxication. In women, the presence of a vaginal discharge which to 
them was a condition not unfrequent or was acquired unknowingly, and 
had no significance, can oftentimes only be made certain by ocular inspec- 
tion. 

Gonorrhceal arthritis, as will be shown later, is usually attended with 
less fever ; fewer joints, perhaps only one, are involved, and there is less 
tendency for the inflammation to shift from joint to joint. 

Acute Rheumatoid Arthritis. — Acute rheumatoid arthritis is, in my ex- 
perience, the most difficult condition to distinguish from acute rheu- 
matism. In fact, except certain general features which may, in mild cases 
of rheumatism, be so modified from the typical standard as no longer to 
form distinguishing characteristics, there are only two things which posi- 
tively differentiate the two diseases. First, its longer continuance fixed in 
the joints originally involved ; secondly, the great tendency which the 
rheumatoid disease has to permanently damage the articulation. Nearly 
all the diagnostic marks of these two diseases which are usually given may 
occur, as exceptions, in either malady, saving the two above mentioned. 
The usual features of rheumatoid arthritis — its more frequent occurrence 
in women in debilitated conditions, uterine or menstrual, its affecting 
more frequently the small joints — will be spoken of more particularly 
under that disease. 

Acute Gout. — Acute gout is much rarer in this country than rheu- 
matism ; it occurs in middle age ; it affects the small joints, more fre- 
quently the great toe ; its local pain is more intense, the redness greater, 
and the skin is dry and subsequently apt to desquamate. These and 
other features, to be given under gout, generally will conduct us to a cor- 
rect conclusion. 

The patient attacked with acute rheumatism generally gives the his- 
tory of exposure to wet or dampness, or of muscular exertion with perspi- 
ration and sudden cooling of the skin.; others speak of nervous shock or 



DIAGNOSIS AND PROGNOSIS. 179 

exhaustion ; and still others — perhaps a much larger number than is com- 
monly thought — in whom the disease develops without apparently any 
antecedent cause of this nature, and who have perhaps been frequently ex- 
posed to cold or even constantly to dampness without untoward results. 

How much value is to be placed on such antecedent circumstances has 
already been indicated ; we must, however, always be prepared to meet 
cases of rheumatism of all forms and grades in which no such account of 
its development is given us, partly no doubt from forgetfulness of the pa- 
tient, and also partly because of the absence of such events. 

Pain. — Unquestionably, in the vast majority of cases, the first symptom 
noted by the patient is pain ; in a few cases fever precedes the pain. The 
pain is rapidly followed by swelling, redness, and heat. The large joints 
are principally affected and begin to suffer first. The temperature rises 
very soon to 102° or 103° Fahr., and remains at about this point ; vari- 
ations occur according to the severity of the attack at evening, and with 
the onset of complications and the involvement of new articulations. The 
pain and stiffness usually remain after the temperature has subsided to 
the normal. 

The peculiar character of the swelling and inflammation of the joints, 
taken in connection with the tendency to shift about from one joint to 
another, form eminently distinguishing features in rheumatism which 
usually will prevent confounding it with other diseases. 

In rheumatism very rarely are the cerebral functions interfered with, 
and never is an attack accompanied with the hebetude or the delirious ex- 
citement of other febrile diseases of equal severity or continuance, except 
in cases where hyperpyrexia supervenes. The only exceptions to this 
rule are those cases of cerebral rheumatism, or in others in consequence 
of a complication involving some one or more of the internal viscera. Per- 
haps, also, there may be mentioned in this connection rare cases of rheu- 
matic involvement of the scalp, in which from the intense pain of its 
swollen fibrous tissues maniacal excitement occurs ; it would seem that the 
symptom is due to the intense suffering rather than, as in other cases, to 
changes of the cerebral functions directly. 

Age. — The age of the patient is of use in determining the nature of the 
disease. Manifestly, however, this consideration is of comparatively little 
value at the outset ; too many cases of acute rheumatism occur at both 
extremes of life for the nature of an individual case to be determined by 
the age of the patient. Acute attacks of rheumatism are, however, more 



180 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

rare in childhood than in those past adult life, so that in one of tender 
rears exhibiting some of the usual rheumatic symptoms, doubts would 
more strongly hold, simply from age, than in an old person ; then, too, 
there are many more diseases occurring in the young than the old, in which 
a simulation of rheumatism is more close. In respect to the chronic 
forms of rheumatism, old age is the period of greatest frequency, while 
childhood is practically exempt. 

Duration of Attack.— -The duration of an attack is frequently an impor- 
tant factor in determining its rheumatic nature. The time is, however, 
very variable ; in the acute attack the symptoms may end in two weeks, 
or be prolonged to five weeks, or even longer with the complications ; the 
milder attacks and those of lesser grade end usually much sooner, but on 
the other hand, seem sometimes to become indefinitely extended, and re- 
sult in a chronic or almost permanent rheumatic condition. These cases 
of lesser grade must be carefully distinguished from rheumatoid arthritis, 
which will be spoken of later. 

These points, taken in connection with the general symptoms of the 
disease, wiU serve to diagnose all cases of acute or subacute rheumatism. 
* 

Prognosis. 

Acute rheumatism, the most painful and the most discomforting of all 
diseases probably, has a strikingly low rate of mortality. Of chronic rheu- 
matism one may say, suffer and be patient, but you will never die. Would 

that one could. 

In considering the prognosis of any particular attack, there are three 
points, or possibly four, to be examined : 1, death from violence of the 
fever; 2, death from cardiac or other visceral complications; 3, disability 
from joint changes ; 4, the liability to second or recurring attacks or to 
chronic rheumatism. 

Death fromViolence of the Fever.— The death from acute rheumatism is, 
as we have said, rare, and results either from hyperpyrexia or from cardiac 
or other visceral complications. It is comparatively recently that the for- 
mer cause has been distinctly recognized ; the use of the thermometer, now 
nearly universal, has brought this source of danger very prominently to at- 
tention, and has likewise brought with it the use of means to combat this 
direct sourc j of danger. This condition of hyperpyrexia has recently, by 
some writers, been claimed as the only direct cause of death in acute rheu- 



DIAGNOSIS AND PROGNOSIS. 181 

matism. They have attempted to exclude the visceral complications, when 
they produce death, classing such results as indirect or due to complica- 
tions rather than to usual and necessary, though exaggerated, symptoms 
of the disease. 

This distinction is, we consider, an improper one, because the visceral 
phenomena which precede death — and the cardiac and cerebral are the 
most common, though still rare ones — do not belong to the same order 
as the frequently occurring valvular changes and pericardial and pleural 
inflammations. These latter are truly complications, and the conditions 
and their symptoms persist often a long time subsequent to the rheu- 
matic attack. 

Death from, Cardiac or other Visceral Complications. — The cardiac and 
cerebral conditions which tend directly to death are of a different order, 
coming during the height of the disease, rapid in their development, and 
subsiding with the rheumatic symptoms when they do not speedily pro- 
duce death. "When they make their appearance, they are as much a part of 
disease as the joint mischief, the fever and the sweating. This cardiac phe- 
nomenon, as distinguished from the usual endocardial complication, is not 
well understood ; its duration is short, death usually resulting so rapidly 
after the appearance of its symptoms that its clinical study is imperfect. 
Some regard it as a pure rheumatic myocarditis ; others as an implication 
of the cardiac ganglia or as a mixture of both these conditions ; others, 
again, as the result of an implication of the nervous centres. Perhaps, 
however, it is not altogether clear wherein these conditions, whether due 
to muscle or nervous involvements, differ from other visceral complications ; 
perhaps they are merely complications occurring earlier in the rheumatic 
attack and involving parts which are more necessary to the continuance of 
life than cardiac valves and serous membranes. We know less, certainly, 
about such conditions than the other and more frequent organic changes, 
and in respect to prognosis of the immediate continuance of life they are 
still more widely distinguished from each other. 

The cases of cerebral rheumatism, which are frequently fatal, are also 
to be viewed as the direct effects of the disease rather than instances of 
visceral complications ; the cerebral symptoms are the effects of vitiated 
blood-supply or of exhaustion of the nervous centres rather than those of 
meningeal inflammation. Perhaps, too, certain cases of kidney failure be- 
long to the direct rather than the indirect effects of the disease ; these 
cases are, however, more rare than either of the others. 



182 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Of the visceral complications, the cardiac is by far the most frequent 
source of a fatal result, and, with the exceptions of which mention has 
just been made, the mischief which leads to death is usually late in 
producing this result. The mischief is an inflammation of the endocar- 
dium, chiefly affecting the valves of the left side of the heart, and comes 
as a true complication of the rheumatic attack. How frequently death re- 
sults from rheumatic heart disease, implicating its valves, is a matter of 
very great uncertainty. Statistics of sufficient extent to be valuable are 
wanting to show how frequent is the occurrence of endocarditis in rheu- 
matism ; after eliminating the cases in which, after the occurrence of val- 
vular disease, complete recovery takes place, it will be found difficult to 
obtain a distinct and clear history of fatal cardiac cases to show which are 
of rheumatic origin and which depend on other causes. Then, too, it is 
but imperfectly known in how many cases of those who, having suffered 
previously of mild attacks of rheumatism, but without cardiac symptoms, 
and coming under observation later with acute attacks are then found 
to have valvular disease, whether the cardiac lesions are due to the former 
rheumatic malady, or whether they acknowledge an independent cause. It 
is not definitely known whether valvular disease of the heart occurs in 
those said to have a rheumatic diathesis, independently of an acute mani- 
festation of the joint disease. 

Death from rheumatic valvular heart disease usually results at a con- 
siderable period subsequently to its primary occurrence. But a valve 
once altered by rheumatic endocarditis, unless the affection is but very 
slight, usually advances with steady, however gradual and slow, steps to a 
fatal termination. Many circumstances tend on the one hand to hasten, 
and on the other to delay, this result. One patient with severe valvular 
disease may postpone the event by a careful life and the avoidance of ex- 
posure to a recurrence of rheumatic attack ; while another, unaware of the 
presence of cardiac disease, so slight are its symptoms, may by over-exer- 
tion damage the diseased valves, or by exposure and want of care bring a 
new attack of rheumatism with renewed endocardial inflammation. 

The other internal visceral complications of rheumatism rarely if ever 
lead to death in this delayed manner ; on the one hand because they do 
not possess the same tendency of gradually increasing in damaging and 
deranging consequences, and partly also that none of them involve organs 
or parts of organs so necessary to life. The pericardial inflammation is 
much more commonly fatal very shortly after its onset, if fatal at all ; but 



DIAGNOSIS AND PROGNOSIS. , 183 

still it occasionally leads to death from the gradual changes effected in 
the relations of the heart by hindering its freedom of motion or by the 
damage inflicted on the heart muscle itself. Both of these changes are 
gradually effected, and make themselves felt after the lapse of consider- 
able time, and they are much rarer results to meet with than the deaths 
from the endocardial changes. The pulmonary and pleural complications, 
too, are usually speedily fatal, if ever ; but they possess little if any power 
of entailing subsequent gradually developed damaging consequences. 

Disability from Joint Changes. — The third element of prognosis, viz., 
disability from joint changes, rarely come to consideration as a result of 
acute rheumatism. Any change of a permanent character said to be the 
result of a single uncomplicated attack of acute rheumatism, is to be viewed 
with the greatest suspicion. Nothing is rarer than a permanent damage 
as the result of rheumatic fever. The older authors recorded many such 
cases, which we know now to be errors of the diagnosis. The diseases 
with which they are connected have, with a fuller knowledge of pathology, 
been separated under different heads. Under the class of mild or sub- 
acute attacks many instances are still pointed out of permanent and often 
progressive articular changes ; these likewise are probably all errors of 
diagnosis, or will in time come to be viewed as such ; some are rheuma- 
toid arthritis, others articular changes connected with nervous diseases 
affecting nutrition — the cerebral or spinal arthropathies. 

Liability to Second or Recurring Attacks, or to Chronic Rheumatism. — In 
respect to the liability to second or recurring attacks of the disease, it is 
very certain that one acute attack neither shields the patient from sub- 
sequent attacks nor from the chronic manifestations of the disease. Nay, 
many hold that one attack directly predisposes to a second. Predisposi- 
tion is, like the question of inheritance, so much a matter of opinion and 
can be so unsatisfactorily determined as a fact by statistics, that it behoves 
all who wish to arrive at the truth, rather than state opinions confidently, 
to be guarded in their expressions. Except on purely theoretical grounds, 
nothing has been advanced to show why one attack of rheumatism should 
predispose to a second or subsequent attacks, and if a predisposition is 
brought about by the first attack, it would seem that two attacks should 
increase such a tendency. Certainly no increasing predisposition from 
these circumstances has been shown, either to subsequent acute attacks or 
to the chronic form of the disease. 

It is probable that in patients who exhibit a recurrence of attacks there 



184 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

is nothing more at most than a strong original tendency to the disease, 
or more probably a mode of life followed and continued by them which 
tends to excite rheumatic disease. While it is true that a very consider- 
able number of patients, who have suffered multiple attacks, are met with, 
it may be said that the sufferings endured dispose such who are wise to try 
and avoid the repetition of them. It is certain that we see very many 
more persons who, damaged by rheumatic valvular disease, escape second 
attacks of acute rheumatism, than there are of those who have recurrent 
acute symptoms. If one attack predisposed to subsequent ones, we should 
expect such attack to occur with especial frequency in persons enfeebled 
by a damaged heart, although allowance, of course, must be made for the 
greater care which the rheumatic cardiac patient is likely to exercise for 
the maintenance of health. 

Predisposition to the Disease. — The belief in a predisposition to the dis- 
ease, and to recurrent attacks, arose from the theory of a diathesis, and 
has since then been held, but, as we have said, without proof of the grounds 
on w r hich its truth is considered tenable. 

From a purely anatomical point of view this belief gains little or no 
credence. In diseases of a type closely allied to inflammation, and in 
which, in addition to the general symptoms of fever, blood-changes, etc., 
there are local lesions of a marked character, a predisposition may be 
brought about by the changes which result from the inflammatory lesions. 
A residuum not in frequently exists, which serves as a favorable basis for re- 
newed or recurrent attacks, and thereby a predisposition to the disease may 
truly be said to be created or increased. A bronchial inflammation, es- 
pecially in attacks long continued, furnishes a striking instance of such 
predisposition. With acute rheumatism it is quite otherwise ; the rheu- 
matic inflammation of the joints is of the most evanescent character and 
leaves behind no traces of its existence. Of the changes in the blood we 
have no comparison to make, as we are equally ignorant of them in this 
disease as in all others of an acute character. 



CHAPTER XYI. 

TREATMENT. 

Treatment of Rheumatism in the Past — General Remedies : Venesection ; Cupping 
and Leeching ; Purgatives ; Diuretics ; Sudorifics ; Woollen Applications ; Moist 
Applications ; Revulsives and Counterirritants ; Blister Treatment — Drugs : 
Colchicum ; Guaiacum ; Cinchona Bark ; Quinine ; Opium ; Antimony and Mer- 
cury ; Veratria and Aconite — Alkaline Treatment : Nitrate of Potash ; Bicarbon- 
ate of Potash ; Citrate of Potash ; Lemon Juice ; Bromide of Potash — Salicyl 
Treatment : Salicin ; Salicylic Acid ; Salicylate of Soda — Mode of Action of the 
Salicyl Treatment : Action of Salicin ; Action of Salicylic Acid ; Action of Sali- 
cylate of Soda — Anaesthetic and other Topical Applications — Diet and Regimen. 

Treatment of Eheumatism in the Past. 

The treatment of rheumatism has in the past, as in the present, been 
as equally unsatisfactory as its pathology. In different ages the remedies 
and means have been varied according to the prevailing notions of 
the causation and nature of the malady, and at all times a great 
deal has been done in a purely empirical or haphazard manner. At 
one time as a new notion of its pathology arose, the treatment was 
ordered in accordance with that belief; at another time — and an 
attempt has been made at this lately — a successful mode of treat- 
ment has introduced new notions of its pathology. This most frequent 
disease, most unsuccessfully treated, especially in its chronic forms, has 
given birth to hordes of cure-all specifics, of which many are in themselves 
good, but like most remedies given in ignorance of the pathology of the 
disease intended to be benefited, are useless if not harmful. 

Our efforts for relief divide themselves for consideration into two 
classes, the general and the local. The general remedies and measures 
have varied in times past from the most active and even violent procedures 
or drugs to the most inactive or inert, from bleedings sufficiently large or 
frequently repeated as to drain the body of this fluid, from almost poison- 



180 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

ous doses of antimony to the " do-nothingness " of mint-water and milk- 
whey. Both of these extremes, as well as the intermediate grades, have 
found their advocates and supporters, and during long years one after the 
other has found acceptance to the exclusion of the rest. 

Of the local remedies, we find those whose object is to modify the mor- 
bid process in its local manifestations, and those which tend simply to the 
comfort and repose of the patient. 

The greatest possible uncertainty exists in the judgment of the value 
of a remedy or course of treatment in rheumatism on account of the un- 
certainty of the duration of an attack. Our studies of the natural history 
of the disease, uninfluenced by remedies, are completely baffled, and the 
only conclusion we arrive at is that variability is its most striking feature. 
On this account, even a very large series of cases give us no positive assur- 
ance that the favorable or unfavorable results are due to the means em- 
ployed to combat the disease. The statements which have been made of 
the value of a certain drug in preventing, for example, endocardial com- 
plications, are, for similar reasons, not to be relied upon, since we are not 
positive what proportion of cases that escape are naturally free from this 
liability. 

In addition to this, our statistics are constantly vitiated, because it is 
well known that at certain times, or during some seasons, greater severity, 
.or, on the other hand, greater mildness of the symptoms, or greater liabil- 
ity or exemption from visceral localizations and complications exists than 
at others. This variation comes from unknown causes, and in respect to 
visceral complications is not proportionate to the severity or mildness of 
the general symptoms. This variation finds its parallel in other acute dis- 
eases. 

General Remedies. 

Venesection. — The oldest recognized method of treatment of rheuma- 
tism, especially in its febrile manifestations, was venesection. This prac- 
tice prevailed as early as rheumatism was recognized a£ a distinct disease, 
but it may be questioned whether it could be looked upon then as in any 
sense a distinctive treatment for rheumatism, since the habit was in all 
acute, and nearly all chronic, diseases to use the lancet. The variation 
w r as not in the remedy, but in the quantity of blood drawn. 

It is probably just as erroneous to condemn or universally prohibit 
general or local bleeding in rheumatism, as it was, according to former 



TKEATMENT. 187 

methods, to universally make use of it. It is certain that very few cases 
occur now which indicate its requirement, although now and again a pa- 
tient is seen about whom the thought occurs, would not some of the con- 
gestions, the intense pain, or even the restless discomfort, be relieved by 
the abstraction of blood locally or by venesection ? 

The old method of bleeding, as practised by Sydenham, though after- 
ward abandoned, and as systematized by Bouillaud, could not fail to be 
harmful. And it became acknowledged, finally, that the use of the lancet 
fails to effect even an abridgment of the acute symptoms ; and as we now 
view the results, it is evident that the convalescence was greatly prolonged 

The notion of the disease on which the treatment was based is now 
contested or denied, though, perhaps, too much stress has been laid on 
this fact in condemning this mode of treatment. Undoubtedly rheuma- 
tism is not a local inflammation, as then thought, but still some of its 
various phenomena are those of inflammation. It would seem more phil- 
osophical to condemn the venesection on the ground that the chief in- 
flammatory symptoms, which it was intended principally to combat, are 
not of a sufficient grade of violence to require such violent or severe 
measures. 

Venesection was practised also on account of a condition of the blood, 
which it was supposed that copious bloodletting would remedy. The 
huffy coat, which was noticed to be more marked in rheumatism than in 
most other diseases, formed a prominent reason for this practice, and it 
was kept up until a supposed reduction in the amount of this blood com- 
ponent was thought to be effected. 

It is hardly necessary to discuss the therapeutic influence of venesec- 
tion since this method of treatment does not correspond with our present, 
or in fact any rational belief of the nature of the malady. It must be in- 
sisted on in respect to this particular measure, as well as for all others 
tending toward depletion, that the constant result of rheumatism is to 
produce anaemia, and that, therefore, whatever may be the present gain 
in abating the acute symptoms, depletion in whatsoever manner effected 
may do in the end more harm than good. 

Cupping and Leeching. — The local abstraction of blood, as distin- 
guished from the general, depends on many special considerations, and its 
use is to be decided on other grounds than those directly connected with 
the rheumatic process. The question of cupping or leeching over or 
around a joint is one that now very rarely would be raised, at least in the 



1SS RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

acute stage of the disease. The generally fleeting character of the articu- 
lar disease would contra-indicate to every one's mind the use of so strenu- 
ous measures, and yet local depletions of this character were formerly 
practised. In cardiac and even pulmonary complications the use of leech- 
ing and wet cupping is frequent. The propriety of these measures must 
be decided by the individual case, and the settlement of the question is 
out of place for discussion here. Each physician will have his own views 
on the subject ; and few will be found who will deny the service some- 
times most strikingly obtained from local depletion in severe cases of 
pericarditis in its early stages. 

The use of dry cupping to the lower vertebral region has been thought 
to modify the severity of the articular phenomena in the lower extremities 
— just the parts in which it is most severe. I can testify to its utility in 
some cases. Although I speak of this measure under local depletion, the 
effect is undoubtedly produced in a general manner through the nervous 
centres located in the spinal cord and connected with the affected articu- 
lations. This procedure has often a very striking effect on the muscular 
and nerve-pains so common in acute articular rheumatism, and also in 
acute sciatica. 

Purgatives, diuretics, and sudorifics, and even emetics, were formerly 
much used in all classes of rheumatic ailments. Bleedings were never 
solely depended upon to subdue the inflammation or to remove the inflam- 
matory condition of the blood, and even by the older physicians a long 
list of drugs were employed to expedite the cure. 

Purgatives. — Of purgatives alone, or in conjunction with other reme- 
dies, magnesium and sodium sulphates have been the most employed. 
This plan of treatment has little to recommend it. It is probably based 
on wrong notions of the disease, and is withal so discomforting and pain- 
ful to the patient that both the moving and exposure incident to it become 
sources of positive harm. Purgation is to-day the fundamental element 
in the treatment, especially of chronic rheumatism, by quacks and nos- 
trum-venders. The idea of it is connected with the old humoral notions, 
and by it the peccant matters are supposed to be removed from the blood 
by exciting an excessive action of the intestinal mucous membrane. Its 
injurious influences are very well stated by Dr. Aitken. First, it is not 
necessary to the cure of the patient, and, like bleeding, tends greatly to 
reduce his strength and protract recovery. Second, from the nature of 
the complaint the patient is quite incapable of moving, and his sufferings 



TREATMENT. 189 

are aggravated. Lis irritability is increased, and his heart's action acceler- 
ated by the repeated shifting of his position, which is rendered necessary 
by the calls of nature. And, third, it necessarily gives rise to more or 
less exposure, which must be prejudicial to a person bathed in perspira- 
tion. 

In respect to the movement of the bowels the usual direction is to se- 
cure a daily evacuation of the bowels ; but while theoretically this injunc- 
tion is a correct one, practically it cannot be carried out during the acute 
stage of suffering. The febrile condition is in itself a considerable obsta- 
cle, and besides, the patient, by voluntary efforts, is able to resist the effects 
of any moderate exhibition of purgatives. It would seem best, therefore, 
in view of the small amount of food taken and insignificant faecal residuum 
from it, to rest content and abstain from purgation until a period of quiet 
and comparative comfort is reached. A movement of the bowels every 
third or fourth day will probably suffice for the requirements of nature, and 
then if necessary — if the stool does not take place spontaneously, as it does 
in the vast majority of cases — a mild purgative is to be given, or an enema, 
if skilfully administered, will suffice for the purpose. During convales- 
cence greater care must be exercised to secure a thorough daily evacua- 
tion, as this does much to restore the tone to the digestive functions, which 
have been in abeyance or disturbed as the result of the acute paroxysm. 
The compound liquorice powder of the German Pharmacopoeia serves an 
excellent purpose, although in the selection of the drug the personal pecu- 
liarities of the patient should be respected. 

Diuretics. — The use of diuretic remedies has been advocated in all 
grades and varieties of rheumatism, and by some observers as a specific 
form of treatment in rheumatic fever. It is certain that in acute rheu- 
matism, and often in other forms of the disease, the secretion of urine is 
defective both in quantity and in the amount of the urinary salts, and 
the object of the diurectic medicines is by increasing the flow of urine 
to promote the general elimination, and also specially of morbid products 
suspected as the cause of the disease. 

This plan of treatment is less to be criticised than the purgative 
method, and is certainly without any special deleterious effects. It is per- 
haps, in all cases, well to bend our efforts toward its promotion. But noth- 
ing has been shown as the result of it which can be claimed as a specific 
influence on the course of the disease. In fact it can be shown very con- 
clusively that so long as the febrile condition is maintained, the secretion 



190 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

of the urine remains uninfluenced by the most strenuous diuretic meas- 
ures. The most efficient diuretics, under these circumstances, are those 
■which tend most rapidly to iufluence, by depressing the fever, remedies 
which ordinarily exercise no power over the urinary secretion. 

As already said, many simple diuretics, or even other remedies, which 
without influencing the quantity of urine change its qualities, are very 
useful in many cases of rheumatism. These remedies are most useful, 
however, in certain of the rheumatic complications, for example, the drop- 
sies which result from the inflammations of the serous membranes, espe- 
cially in their chronic stages. 

Sudorifics. — The characteristic and profuse perspiration has been con- 
sidered as one of the principal efforts of nature in getting rid of the 
morbific materials productive of the acute paroxysm of rheumatism, and 
this circumstance has been seized upon as an indication for treatment. 

The idea, as a specific means of treatment, is based upon mistaken no- 
tions, a legacy of the humoral pathology, and the results obtained by this 
method show no alterations in the course, the severity, or the duration of 
the disease. The amount secreted by the skin, in ordinary cases, is so 
great it would seem that the perspiration could not be advantageously in- 
creased. The circumstances in which sudorific measures offer advantages 
are those in which the skin is deficient in its action, but the cases of acute 
rheumatism with a dry skin are exceedingly rare. 

The sudorific remedies which have been employed are those which act 
generally, and those applied for local effects. The most common agent, 
the one which even now finds great acceptance, and in many cases proves 
itself useful in meeting a variety of indications, is Dover's powder. This 
remedy is especially applicable in the commencement of an attack, though 
by many practitioners its use is kept up throughout the acute paroxysm, 
and its narcotic effects are useful even when its sudorific action is not 
called for. Dover's powder finds frequent use in connection with other 
remedies, especially when the alkaline treatment is pursued. 

Woollen Applications. — Another sudorific measure which has com- 
manded, and still commands approval in all forms and grades of rheu- 
matic disease, is the use of means for enveloping the whole body or only 
joints in warm clothing or wraps. This treatment has been recommended 
as the only measure to be adopted for acute rheumatism, or it has been 
tried in common with some simple diluent drinks, and the results have 
been warmly praised. 



TREATMENT. 191 

Its object is held to be twofold, first, in promoting cutaneous action, 
and secondly, in shielding the body from the effects of cold and draughts 
during the perspiring condition. The material recommended is woollen, 
especially flannel garments, and many hold to a special virtue in red flan- 
nel. The shops contain varieties of medicated red flannel for sale, many 
of which are positively dangerous from the presence of irritating or poi- 
sonous dyes used in their manufacture. 

In acute rheumatism certainly nothing can be more discomforting to 
the patient than the contact of woollen raiment, and add to this the dis- 
gusting condition in which such clothing soon becomes from the abun- 
dant sweat and the necessity for changing it frequently, with a greater lia- 
bility to cold, there is certainly a question of the propriety of its use. In 
chronic rheumatism and during convalescence this habit of dressing is 
generally a necessity, and the value of flannel worn next the skin in pre- 
venting rheumatism, especially for those predisposed to attacks, is well 
known to all. 

During the presence of the articular inflammation it is a common 
practice to envelop the joints in raw cotton or in wool ; on the other 
hand, the procedure is condemned by many, under the notion that by in- 
creasing the warmth and the consequent flow of blood the conditions for 
inflammation are augmented. The majority of patients, however, find 
comfort from the application, and those accustomed to rheumatic disease 
crave its use. 

Moist Applications. — Frequently in addition to the simple envelopment 
of the painful parts, lotions of various characters are used. Both sedative 
and alkaline applications, or their combination, find many advocates, and 
their effect is often very salutary in allaying the pain. In making moist 
applications to the inflamed joints it is necessary, so great usually is the 
heat of the skin, to surround them with an impermeable covering, such as 
waxed paper, gutta-percha cloth, etc., to prevent the rapid evaporation 
and the necessary renewal of the application. The impermeable covering 
retains the moisture, increases the heat, and consequently the flow of 
blood to the parts thus enveloped to a much greater degree than the dry 
application, and owing to this fact a greater objection is made to them 
than to the former. It is certain that on this account the moist applica- 
tions are not serviceable in all cases ; many cases are not benefited by 
them, and they even increase the pain and discomfort of the patient. It 
has seemed to me— and recently I have made a pretty careful trial in 



192 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

order to find the class of cases in which moist applications are useful — 
that only those are benefited when the intra-articular inflammation was 
marked, when the capsular ligament resisted the expansion of the accu- 
mulating fluid, and when the peri- articular tissues failed to swell. These 
are the cases in which the pains are generally the most severe. The 
moist and warm application served its useful purpose by softening or 
causing the peri-articular tissue to swell, and thus relieved the pressure of 
the effusion within the joint. In addition, we can believe that the nar- 
cotic — usually opiate — lotions have their ameliorating influence here as 
under other conditions in assuaging the pain. In respect to the alkaline 
fluid, though originally used for its antidotal or neutralizing action on 
the acid effusion supposed to be present, we know of nothing confirma- 
tive of such action, though I believe that it is often useful ; for example, a 
strong solution of sodium carbonate, in softening the otherwise hard and 
tense skin, especially around the knee-joints. For this purpose and 
under these circumstances we find local applications to a limited degree 
serviceable. 

Revulsives and Counter-irritants. — The application of revulsives or coun- 
ter-irritants to the inflamed joints is a method which has been always 
more or less in vogue, from very early times even to the present. "With 
our present knowledge of the therapeutic action of irritants apjxLied to the 
skin, the use of a severe application over an inflamed rheumatic joint does 
not appear to be a rational procedure. The effects of such measures would 
seem rather to increase the tendency or the conditions favoring inflamma- 
tion in the adjacent synovial membranes. The more severe the irritation 
of the skin, the more marked would be the effects within the joints, 
whereas, according to our present belief in the mechanism of trophic 
nerve action, the counter-irritation should be of the mild character, con- 
tinuously or frequently applied in order to produce the best results. The 
milder applications can be applied directly over the inflamed joints, while 
the more severe should be made to the adjacent parts. 

As a specific treatment of acute rheumatism none of these applications 
have met with more than a very slight approval, and by nearly all writers 
are spoken of in combination with other remedies of an internal character. 
In chronic rheumatism, however, they find a very constant use, and also in 
the subacute forms as well as in the late stages of an acute attack where 
the articular disease lingers. 

Blister Treatment. — In June. 1864, Herbert Davies delivered a clinical 



TREATMENT. 193 

lecture at the London Hospital " On the Treatment of Rheumatic Fever 
in its Acute Stage, exclusively by free Blistering." Dr. Davies' method was 
not applied by him in view of the principles above spoken of, but, as he 
says, "believing it probable that the virus localized itself for a time in the 
inflamed joints, and that the intensity of the local inflammations was a 
measure to some extent of the amount of poison collected by a species of 
affinity in the parts attacked, I determined to attempt the local elimination 
of the materies morbi, wherever any external manifestations of its presence 
existed. I ordered blisters, varying in width, but of considerable size, 
according to the locality, to be applied around each limb, and in close 
proximity to the parts inflamed ; and I hoped to relieve the affected 
joints, partly on the principle of derivation, but mainly and really by 
affording through the serous discharge from the blistered sircface a 
ready means of exit for the animal poison. Armlets, wristlets, thighlets, 
and leglets, and even fingerlets, were applied near to, but not upon every 
joint inflamed, at the very height of the inflammatory stage when the local 
pains were the most severe, and the constitutional disturbance the 
greatest" 

It was claimed for the blister treatment that it effected a shortening ox 
the duration of the acute paroxysm, and especially lessened the liability to 
heart complication. This suggestion of Dr. Davies', and especially his 
manner of applying the blisters, attracted great attention, gave a new im- 
pulse to this plan of treatment, and gained many followers. The mode, 
however, never received general acceptance, and has since fallen into disuse. 
Although according to Dr. Davies' report, and those of many others, the 
blisters relieve the pain, quiet the pulse, and after their use the urine be- 
comes alkaline, still nothing specific has been shown from their effects, and 
it is self-evident that under many other plans of treatment, and even no 
treatment, the same result follows in equally severe cases with equal rapid- 
ity. The severe blistering is regarded by many as barbarous, and while 
this ought not to preclude the use of them, if distinct advantages result, 
still the idea forms with many patients a bar to the application. 

The production of strangury has been made an objection to the use of 
cantharidal blisters ; but the reports of the cases show that this condition 
is a rare one resulting from their use, and in a disease attended with so 
great deficiency of urine, and also difficulty in passing it, there is great 
liability of misjudging the effects of such a remedy. 

It must be mentioned in this connection that in the serum of the : 



194 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

blisters no lactic acid has been shown to be present. This acid is, however, 
one most difficult to obtain from any organic fluid, and the failure to ob- 
tain it in the few experiments which have been made with this object in 
view, cannot be quoted as positively proving its absence. 

The application of blisters has always been in use in the treatment of 
various visceral localizations ; for example, pericarditis, pleurisy, and the 
cerebral inflammations, etc. 



Drugs. 

Of the very long list of drugs which have been employed and have 
been discarded, or still find occasional use, a few require special mention 
and discussion. Many of this class were used purely empirically, others in 
accordance with some pathological theory. 

Colchicum. — Colchicum and its preparations were held at one time to 
exercise a specific influence on the rheumatic process, or to promote the 
elimination of the rheumatic poison. This belief probably arose out of 
the similarity of this affection with gout, and at the time when the two 
diseases were imperfectly distinguished. Later the use of the remedy 
was mainly in connection with other drugs as an adjuvant to them, or in the 
promotion of some particular organic function. In small doses it has 
been thought to promote elimination by the kidneys ; but in this way acts 
independently of the rheumatic condition. In large doses the remedy is 
regarded as useless, if not positively dangerous, in acute rheumatism. It 
is without influence in altering the course of the paroxysm of fever, very 
unlike its influence on the gouty inflammation. 

The favorable reports given of its influence in acute rheumatism have 
arisen from the mistaken diagnosis of the two diseases, or very probably 
from its unquestioned effects in depressing the heart's action, and the re- 
lief of pain, etc., due to the lowering of the vascular tone. It is for this rea- 
son that colchicum is often a dangerous agent in rheumatic affections in 
which the heart is especially liable to be diseased. 

Guaiacum. — Guaiacum is another remedy which has been recommended 
in acute rheumatism, but apparently with even less reason than colchicum. 
It has never been shown to alter the course of the disease, and during the 
acute symptoms usually shows less influence on the secretion than during 
health. This remedy finds more use in chronic conditions. 

Cinchona Bark. — Cinchona bark was formerly considerably used in the 



TREATMENT. 195 

treatment of acute rheumatism. Its first employment was limited to cases 
of the disease exhibiting an intermittent type. But later, especially after 
the use of the alkaloid became common, and rendered its employment 
more convenient, its systematic and routine use was advised, and the 
remedy was given in heroic doses. 

Quinine. — Quinine has never found general acceptance as a remedial 
agent in acute rheumatism ; but about forty years ago, especially among 
French writers, it was highly recommended as having a most marked effect 
on the course of the fever, and in allaying the articular inflammation. To 
produce these effects the dose must be from twenty to ninety grains, given 
during twenty-four hours, and in these quantities it is usual to find that 
both the stomach and the nervous centres are unfavorably affected. By 
allaying the fever it was thought to lessen the liability to cardiac compli- 
cations ; but if these were present it seemed not to affect the general con- 
dition of the patient or the complication unfavorably. 

The use of quinine, in both large and small doses, very soon fell under 
the suspicion of inducing cerebral symptoms, and was mostly abandoned 
even by its earnest advocates. This suspicion was probably in great de- 
gree an unjust one, and although unquestionably in this, as well as in 
other febrile maladies, the nervous susceptibilities, and even certain ner- 
vous phenomena are excited, it cannot be held that the graver forms of 
cerebral rheumatism are due to its use. The giving of quinine must al- 
ways be subordinated to the effects which it causes on the side of the 
nervous system. 

Primarily its use is directed, from the point of view of a rational pathol- 
ogy, by the control which it exercises through the nervous system on the 
febrile process, as well as on the articular disease. It cannot be shown 
that the drug has any specific influence in controlling the rheumatic pro- 
cess, and hence we are driven to accept this explanation of its action. It 
is therefore to be considered as an antipyretic, and from the valuable qual- 
ities of the drug in this respect, in so many diseases and under so many 
circumstances, it is deserving of investigation. 

We cannot deny to it very serviceable effects in certain conditions, in 
what may be described as a regulating action of the nervous system, 
although, as alluded to above, its inopportune or excessive administration 
serves to exaggerate or even to develop untoward nervous phenomena. 
Again, it may serve well, mitigating the febrile and the articular processes 
in acute rheumatism, as well as in many cases of the subacute or chronic 



196 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

forms of the disease ; but except in its effects in this direct manner, it is 
inoperative against the development of the visceral complications. 

In very many cases of rheumatism the tendency to remittance in its symp- 
toms is of very common occurrence. These recurring phenomena are fre- 
quently, though probably nearly always, incorrectly set down to the effects 
of so-called malaria ; the phenomena are commonly of a nervous character. 
The use of quinine is most auspicious in breaking up this so-called perio- 
dicity, and acts apparently by its regulative effects in modifying the nervous 
functions. In the same manner it is serviceable in warding off relapses of 
the diseases. There are also a number of minor symptoms of the disease 
for which quinine may be given, according to certain general principles 
furnished for its administration, apart from the presence of the rheumatic 
disease. One of these is the excessive sweating, in the modification of 
which quinine is useful. 

Viewed as an antipyretic agent, quinine may be considered a very ser- 
viceable agent in the treatment of acute rheumatism, but to effectively 
modify the temperature it is necessary to employ often very large doses. 
In this respect it is less certain in its action than other remedies, or than it 
is itself in other diseases, and while less certain in its effects the large 
doses of the drug often produce perturbation of the nervous functions 
or of the digestive f mictions. 

More recently quinine has been used in combination with other reme- 
dies. Garrod, in "Reynolds's System of Medicine," has proposed this 
modification, and no one is more entitled to be heard on this subject than 
this careful observer and writer. Let us quote his opinion. " During the 
last ten years (writing in 1867), since the publication of his paper on the 
treatment of rheumatism with large doses of bicarbonate of potash, the 
writer has made a very extensive use of the following plan, from which he 
thinks he has obtained more valuable results than from any other ; it may 
be termed the quino-alkaline treatment, and is thus practised: Sul- 
phate of quinine is ordered to be rubbed up with a solution of bicarbon- 
ate of potash, to which a little mucilage and some aromatic, as tincture of 
cardamoms or spirit of chloroform, is subsequently added ; each ounce and 
half dose contains five grains of quinine and thirty grains of the potash 
salt, the quinine being reduced to the state of carbonate. To the adult 
the above dose is given every four hours, and persevered with until the 
joint affection and febrile disturbance have completely abated. When the 
quino-alkaline treatment was first made use of, a few days were allowed 



TREATMENT. 197 

for the exhibition of the alkali alone, and then the quinine was added ; but 
of late the quinine has been given from the first ; it neither increases the 
thirst nor the furred state of the tongue, and its influence upon the heart 
is to lower the pulsations, but not to weaken them, and hence, when peri- 
and endo-carditis are present, its employment is not contra-indicated. If 
cardiac complications exist, local depletion and counter-irritation may be 
made use of." " If desired, the citrate of potash, or some other alkaline 
salt with a vegetable acid may be substituted for the bicarbonate." " Al- 
though the results obtained from a large number of trials have not yet 
been tabulated, the writer feels assured that the above treatment is much 
more efficacious than the simple alkaline plan ; that there is far less ten- 
dency to the occurrence of relapses, and that the patient is left in a more 
satisfactory condition after the cessation of the febrile disturbance." 

Opium. — Opium has been used for two purposes in acute rheumatism ; 
first, for its narcotic effects, and secondly, in combination usually with 
other drugs, for its diaphoretic action. Of the latter an account has al- 
ready been given in speaking of Dover's powder. For its narcotic effects 
it is legitimate to use opium or some of its preparations under all circum- 
stances and in every condition, when the pain, usually of the inflamed 
joint, but occasionally of other parts, is so severe, and so long continued, 
that the suffering of the patient prevents sleep or renders his condition 
unbearable. 

In early times opium was used for its specific effects on the rheumatic 
inflammation. It was thought, by its calmative action on the circulation, 
or by other means, to tend directly to lessen the inflammatory process ; 
but later authors, especially Cullen, condemned its use during the febrile 
stage of the disease. 

However, its use was continued for this and other purposes, and in 
combination with other drugs its applications were innumerable and be- 
came almost universal. These combinations were made with the purpose 
of checking the over-action of many remedies, which in themselves were 
thought to serve a specific purpose in the treatment of the rheumatic con- 
dition. Its combination with calomel was made in order to check the ac- 
tion of the bowels, and, as it was said, to prevent this drug from being 
drained off and thus failing of its proper absorption, and its effects on the 
inflammatory process. Opium has also been used in connection with col- 
chicum, quinine, digitalis, veratria, and belladonna or its alkaloid atropia. 

Later, the use of opium was highly recommended by Corrigan and 



19S RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

others, but we fail to discover from their accounts any further effects from 
it than those already detailed. It served to assuage the pains of articular 
inflammation, leaving the patient comfortable until the subsidence of the 
disease in its natural course. 

Antimony and Mercury. — The antimonial and mercurial remedies have 
been advocated for their direct effects in modifying the course of the 
acute paroxysm ; but their use has now been almost entirely abandoned, 
except to meet some special indications. The former were received with 
favor, doubtless owing to their general depressant action, which was often 
carried to such extremes that no active morbid process could for the time 
be carried on by the overpowered vital forces. The latter were employed 
for their general antiphlogistic effects, and especially for the prevention 
as well as the treatment of cardiac complications. Their influence on the 
rheumatic process has not been shown to exist, and their effects in cardiac 
complications is based both on mistaken notions of the morbid process 
and on the general effects of mercurials ; this is especially true in regard 
to endocarditis. The effect of mercury is not perceptible in preventing 
or arresting the inflammation, and may do harm in breaking down the 
collecting fibrin which shields the roughened and inflamed endocardium. 
A comparison of the results of mercurial treatment with those of other 
remedies shows no preponderance in their favor ; in fact the condition of 
the patient during convalescence, if ptyalism has been induced, is much 
less favorable. 

Veratria and Aconite. — Both veratria and aconite have been recom- 
mended for their favorable effects in combating the fever and for allaying 
the pain of the acute paroxysm, but have only met with temporary ac- 
ceptance. Although they have unquestionable action in both these re- 
spects, given alone or in connection with opium, the indications which they 
fulfil are generally much better met by other remedies. 

Alkaline Treatment. 

The plan of treatment, which consists in the administration of the alka- 
line bases, is divided for consideration into two heads : the one, in which 
merely various saline materials were given, the other, in which these salts 
were especially intended to produce their effect by their alkaline charac- 
ters. The action of these two classes of remedies however, does not differ 
probably very materially the one from the other. Given in the usual 



TREATMENT. 199 

manner and in ordinarily used doses, they are intended to produce altera- 
tion in blood, and hence are both directed to the same end, and their 
effects may be discussed together. 

Nitrate of Potash. — The earliest used saline was probably nitrate of pot- 
ash, and its employment arose from the common practice of giving saline 
mixtures in all febrile maladies, especially those of an inflammatory type. 
At first this salt was brought into prominence by Brocklesby, who used it 
in connection with venesection. The blood-letting was intended to sub- 
due the inflammation and the fever, and the alkaline qualities were to 
serve the purpose of breaking down the inflammatory products and pro- 
moting their absorption. The practice was introduced more than a hun- 
dred years ago, and has been continued more or less intermitting up to 
the present time. 

The results of the treatment have been reported by many to be very 
favorable, shortening the duration of the malady and favoring a rapid con- 
valescence. Fuller and others who have employed this remedy do not 
agree in this view, and in quoting the results obtained by Basham and 
others who used the nitre treatment, criticise their reported favorable re- 
sults as not confirmed by the details of their cases. 

The dose of the nitre, in order to exercise any influence, must be very 
large. One ounce or two, or even three ounces, are given during twenty- 
four hours, very largely diluted either in water or in water gruel. Taken 
in divided doses at short intervals, it was said to produce no disturbance 
of the digestive function or of the abdominal organs ; others, however, do 
not confirm the mild effects on the stomach here spoken of, and alluded to 
nausea, vomiting, and diarrhoea, which compel the discontinuance of the 
drug. 

My own experience in the use of nitre is very small, and is confined to 
the use of much smaller doses, which seemed to be without influence on 
the symptoms, and which, in fact, given even in the reduced doses, quickly 
disagreed with the stomach, leading to the abandonment of its use. 

The exact therapeutic effect or the chemical reactions of nitrate of pot- 
ash are not known. It is one of the salts which under all circumstances; 
is found in urine shortly after its ingestion. 

The alkaline treatment proper has found its most earnest advocates in 
Dr. Fuller and Dr. Garrod. It took its rise from the gradual development 
and acknowledgment of the new view of the pathology of rheumatism, as 
well as a greater accuracy of the knowledge of its symptoms. It was the 



200 RHEUMATISM, GOUT, AND ALLIED DISOKDERS. 

answer to the demand that the acid condition of the "body should be neu- 
tralized by opposing it with an alkaline base with which it could combine 
and thus be rendered innocuous. It was the attempt to cure disease by 
chemical reactions rather than by controlling vital action. It was the ac- 
ceptance of the fact that lactic acid was the cause of the disease rather 
than that both the disease and the supposed lactic acid were the outcome 
of a perversion of normal action. It was an effort to treat one of the pro- 
ducts of disease; and not the disease itself. All of these ideas led to the 
systematic use of alkalies, which in the hand of Fuller, Garrod, and a host 
of others, has constituted the chief means of combating rheumatism dur- 
ing a quarter of a century. 

Garrod says that they were not " systematically " employed until the 
year 1847, when Dr. Wright published a communication on the subject. 
Since that time both Fuller and himself made full trials of their use, and 
after the publishment of their results, the use of these remedies became 
common. "The form in which," says Dr. Fuller, "I usually prescribe the 
remedies, is that of an effervescing citrate of potash or ammonia draught, 
with an excess of from forty to sixty grains of the bicarbonate of potash 
or bicarbonate of soda, to which, if the patient be strong and exhibits 
the usual symptoms, I usually add a drachm or more of the acetate of 
potash, and ten or fifteen minims of the vinurn colchica." "This draught 
is repeated, for the first twelve or twenty -four hours, at intervals of two, 
three, or four hours, according to the strength of the patient and the se- 
verity of the attack." " In proportion as these symptoms of amendment 
manifest themselves, so is the dose of the alkalies decreased, until, after 
the lapse of three or four days I feel justified in commencing the admin- 
istration of quinia or bark, in combination with small doses of bicarbonate 
of potash." The author did not confine his recommendation exclusively 
to the alkaline treatment : " Alkalies in many cases prove unequal to restore 
a healthy state of assimilation and to prevent the further formation of 
acid in the system," " but no certainty can be felt as to arresting the dis- 
ease, without the aid of other medicines to assist in modifying the func- 
tion of assimilating and to act on the various excretory organs." 

Bicarbonate of Potash. — Dr. Garrod's plan of treatment consisted of 
" administering a dilute solution of bicarbonate of potash in about thirty- 
grain doses, every four hours, until the joint symptoms and febrile dis- 
turbance have completely disappeared. These doses produce no inconve- 
nience either to the stomach or bowels ; the urinary secretion is not nota- 



TREATMENT. 201 

bly increased, but its character is completely altered ; and the reaction 
becomes either neutral or alkaline ; it usually remains clear, but occasion- 
ally gives rise to a deposition of the triple phosphates. Upon the heart 
the alkaline bicarbonate acts as a sedative, reducing the frequency of the 
pulse sometimes forty-eight beats in the minute, but not causing any 
faintness. When the patient is fully under the alkaline treatment, the 
blood is distinctly altered, and the coagulation of the fibrin takes place 
more slowly." The author has since his first trials with the simple alka- 
line treatment found cause to change his method, preferring the results ob- 
tained from his modification of it, viz., the quinia- alkaline treatment, the 
details of which I have already given. 

Other forms of the alkaline salts besides those mentioned have been 
employed, and still find use in the treatment of the disease. Both of the 
salts mentioned are combined either with a fixed mineral acid or carbonic, 
and these find direct entrance into the blood and are eliminated from th9 
kidney in the same state. The alkaline carbonates are supposed to have 
the advantage, in addition to their effects in and on the blood, of neutral- 
izing any acid with which they come in contact in the digestive tract. 
Thus they operate on the acid state of the system both in the primary pro- 
cess of assimilation and on the acid products which are derived from the 
secondary assimilative process. 

Citrate of Potash. — The other forms of alkaline salts which are used are 
those in combination with vegetable acids. The type of these is the 
citrate of potash. Their character is that of neutral salts, and they are 
without effect, at least so far as we are acquainted, on the acidity of the 
mucous membranes, but their action on the blood is similar to that of the 
alkaline carbonates, into which they are decomposed. They appear in the 
urine as basic carbonates of the salt used. 

The results of their action in rheumatism appears to be equally good 
with that of other alkalies, and indeed they appear in many cases to serve 
a better purpose. 

Lemon Juice. — Before closing the subject of alkalies let us consider 
the treatment by the use of lemon juice. The connection between the 
two modes of treatment is a pretty close one. The difference between 
the administration of an alkali and an acid, at first glance, seem as great 
as possible ; but the similarity of the two kinds of remedies is very great, 
especially the latter class of alkalies just discussed. Dr. S. Owen Eees, 
who first discussed its action (1849) and carried out the use of the rem- 



202 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

edy, thought that the acid juice containing a considerable amount of 
oxygen by decomposition, and the blood, favored the conversion of the uric 
acid into urea, and perhaps carbonic acid, and thus promoted its elimina- 
tion. The urine, under its action, becoming neutral or alkaline, and the 
excess of urates disappearing. The presence in the lemon juice of the 
potash, salts, to a certain degree conforms its action to the alkaline mode 
of treatment. 

The remedy is given in doses of three to eight ounces of the fresh 
juice at intervals during each day. It was claimed that its use moderated 
the heart's action and afforded relief to the articular pains. Given in 
these large doses, although the contrary was claimed, it certainly tends to 
disturb the stomach, exciting colicky pains, and often producing diarrhoea. 
If it removes the peculiar smell of the acid perspiration, it replaces it with 
the acid smell of the lemon, which hangs around the patient even a long 
time after the remedy is discontinued. 

This treatment, from its novelty and simplicity, attracted general atten- 
tion, and was for a time extensively used, but has now fallen entirely out 
of favor. It is oftentimes hard to carry out the treatment, both in private 
and in hospital work. I have found lemons particularly expensive, diffi- 
cult to obtain, or lacking in juice at seasons when acute rheumatism is 
especially prevalent. A number of substitutes have been proposed and 
used for the juice of fresh, lemons ; for example, lime juice and citric acid, 
but these preparations have not been found more serviceable than lemon 
juice, and have been used only when that article was not to be obtained. 

The use of lemon juice, according to the common judgment and the 
results of subsequent experience, has not been shown to modify the course, 
duration, or the occurrence of complications of acute rheumatism, but it 
is not to be summarily dismissed from the list of agents useful in this 
disease. On many occasions and for different purposes it will be found 
applicable, and its administration may be carried out as an adjuvant to 
other treatment, or when a failure results with other methods, in mitigat- 
ing the patient's sufferings. 

Bromide of Potash. — Bromide of potash, subsequent to the introduc- 
tion of the bromides into the Pharmacopoeia for the treatment of other dis- 
eases, found a frequent application in cases of rheumatism. It was fre- 
quently given in place of opium for its general soothing effects, but espe- 
cially in cases attended with various nervous phenomena,, and also when 
actual rheumatic localizations developed in the nervous tissues, in which 



TREATMENT. 203 

instances it was thought that opiates tended to increase these symp- 
toms. 

The remedy is of great service in patients addicted to the use of alco- 
hol, in whom congestion, and, perhaps on account of the rheumatic attack, 
the condition of alcoholic delirium is threatening to develop. In cases of 
simple delirium and extreme nervous agitation, occasionally seen in acute 
rheumatism, the effects of even a few doses of the bromide given as re- 
quired suffice to calm the patient completely, allowing the disease to con- 
tinue its usual course, and the patient's general condition and the excre- 
tory function is undisturbed by the exhibition of the drug. 

However, no attempts were made at the time of the introduction of 
the bromides into medical use to confine the medication of acute rheuma- 
tism to this drug until 1865, when Da Costa, having " while treating some 
patients troubled with great restlessness and pain during rheumatic fever, 
prescribed the bromides to allay these symptoms, and finding them to act 
favorably, was led to study their influence on the course of the disease." 
The particular drug employed by him was the bromide of ammonium, air 
though the salt of potash was also tried. His early observations extended 
over more than thirty cases of acute rheumatism ; " all the cases were 
marked ones ; most of them would be called severe ones. " The records 
of these cases were published in the "Pennsylvania Hospital Keports"for 
1869. 

The results of this plan of treatment are certainly as favorable as shown 
by any other that has been proposed. The mean duration of the attacks, 
from the initial symptoms to full convalescence, was 22.5 days, and the 
group of cases include two long cases, ill and under alkaline treatment for 
a considerable period before admission to the hospital. The mean time 
under treatment in the hospital was 14.16 days. The period bears a very 
good comparison to that reported by others. 

The influence of the remedy on the pulse showed the reduction in the 
number of beats was promptly affected, " rendered decidedly slower, and 
often also loses in force." On the skin "its influence was not very de- 
cided ;" " but, in so far as it seemed to have any, it appeared to promote 
perspiration. It certainly seemed to do so in the cases associated with a dry- 
ish skin." The temperature does not appear to be markedly influenced by 
the remedy ; the thermal curve usually gradually returning to the normal 
level with the subsidence of the joint disease. The influence on the res- 
pirations was not particularly studied, since this function, owing to pain 



204 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

or to the constrained position in which, the patients are apt to lie, prevents 
any accurate appreciation of whether its frequency is altered by the malady 
or by the drug. " On the pain the influence is very striking. Not only is the 
local distress often stated to be ameliorated, but the general restlessness 
and uneasiness are decidedly benefited." The remedy gave rise to no gastric 
symptoms, nor did it constipate. In a few, indeed, it produced slight 
diarrhoea. The urine remained acid during the administration of the 
remedy, but its quantity was decidedly increased. The bromide made its 
appearance in the urine, in very small proportion or none at all, and " cer- 
tainly out of all proportion to the amount swallowed." 

In respect to cardiac complications the report shows " that not a single 
one had endocarditis originating under treatment ; in not a single one 
was it met with .... in which it had not existed at the admission 
of the patient into the hospital." Of pericarditis "four cases are the only 
ones among the thirty under analysis." " Nor was there a special ten- 
dency to relapse ; for a relapse only happened in three." " As regards 
the immunity from heart affection, the bromide treatment ranges itself 
alongside the alkaline treatment, which it seems to me to suqDass in the 
greater influence on the pain, in the healthier, less ansemic look of the pa- 
tient on recovery from the acute symptoms, and the speedier convalescence." 
The bromides "were, for purposes of observation, given alone." "They 
could be conjoined in special cases to alkalies, or to any remedy that the 
particular symptoms of the case might seem to render most advisable. 
Moreover, as we find with every treatment, there will be cases in which it 
may not suit. It is but a plan of treatment, attended, I believe, with good 
results. But it remains to be worked out to what cases it is the most 
applicable, and in which its success is most striking." 

Having personally seen a good deal of the results of the bromide 
treatment in the hands of others, and especially Dr. Da Costa's, and having 
used it considerably in my own work, I am prepared to confirm its good 
effects, and to testify that its merits are such in certain cases that no other 
remedy quite fills its place. After becoming familiar with its effects in 
rheumatism generally, it becomes comparatively easy to recognize, without 
perhaps being able to define or portray the class of cases in which the 
remedy is likely to be useful and successful. 






TREATMENT. 205 



Salicyl Treatment. 



The treatment of acute rheumatism with this class of remedies, of 
which there are a large number, though only a few of them have been ac- 
tually employed, dates back about six or seven years. Since then they 
have come very largely — nay, almost universally — in vogue, and have re- 
ceived the very highest praise. 

Salicin. — The first one of these compounds to be used in acute rheu- 
matism was salicin. Maclagan, of London, commenced his observation on 
the subject in November, 1874. The other compound, the salicylic acid, 
was first used in Traube's clinic in Berlin, and the account of its action 
was published two years later in the Berliner klinische Wochenschrift, 
January, 1876. 

Since these compounds are comparatively new remedies, at least in 
their present applications, let us- glance at their nature and the history of 
their use in this disease. Salicin was discovered in the latter part of the 
first third of this century, the willow bark from which it is derived having 
been used for similar purposes nearly two centuries. Salicin being con- 
venient for administration, was very considerably employed as a substitute 
for the cinchona alkaloids, and favorable reports were made of its antiperi- 
odic effects in inter- and re-mittent fever, and also of its febrifuge qualities. 

Maclagan was led to the employment of the willow-bark alkaloid, as he 
says, from consideration of the nature of the disease, and the qualities and 
nature of this drug, and not purely empirically. The method of reasoning 
which controlled him was as follows : "In connection with the action of 
quinine on the various forms of intermittent and remittent fever, and in- 
deed in connection with the action of the cinchonacese generally on the 
diseases of tropical climates (ipecacuanha in dysentery, for instance), 
one fact had always strongly impressed me — that the maladies on whose 
course they exercise the most beneficial action are most prevalent in 
those countries in which the cinchonacese grow most readily — nature 
seeming to produce the remedy under climatic conditions similar to those 
which give rise to the disease." 

"Impressed with this fact, and believing in the miasmatic origin of 
rheumatism, it seemed to me that a remedy for that disease was most 
hopefully to be looked for among those plants and trees whose favorite 
habitat presented conditions analogous to those under which the rheu- 
matic miasm seemed most to prevail 



206 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

A low-lying damp locality, with a cold rather than warm climate, are 
the conditions under which rheumatism is most likely to arise. 

On reflection, it seemed to me that the plants whose haunts best cor- 
responded " to this description were those belonging to the natural order 
Salicacea? — the various forms of willow." 

This form of argument is not new, it has been applied many times to 
other diseases and natural products, and often with not greater accuracy, 
or perhaps with as much of pure imagination as in the present instance. 
The details of this special argument are defective, and to criticise it on no 
other ground than the error of topography, on which the author quoted 
seems to rely, is quite sufficient. The quinine -bearing trees grow on 
mountain elevations, far from swampy regions and in a climate approach- 
ing that of the temperate zone, and the willow's favorite haunt is the 
swamp, which if it produces rheumatism, is also the birthplace of the inter- 
mittent fevers. 

Imaginative reasons like this should cast no imputation on the value of 
a drug, whatever else they may do. The therapeutic means must be tested 
by its results, and not by the way they were suggested for use. However, 
when one starts with & priori reasons, perhaps dictated by a prejudice, in 
favor of a method of treatment, it is well to be cautious in judging of 
the results and of the effects on the disease for which it is administered. 

The manner of administration Maclagan describes as follows : " The 
salicyl compounds are so rapidly eliminated that their full beneficial effects 
can be got only by giving them frequently, as well as in full dose." "It 
takes about an ounce of salicin to remove the acute symptoms. That 
quantity should be taken within the first sixteen or twenty-four hours, 
in doses of twenty to forty grains, at first every hour, and then every 
two hours, as the acute symptoms begin to decline. A second ounce 
should be consumed in the next forty-eight hours. After that, twenty 
to thirty grains may be taken every four hours, for two or three 
days ; and for a week or ten days more that quantity should be taken 
three times a day. By that time the patient will most likely be safe. 
Any threatening of a return of the rheumatic symptoms must be at once 
met by a return to large and frequently repeated doses of the remedy." 

Two years later this author gives an account of his experience with the 
drug. To abbreviate this account the statement is as follows : " From so 
small an experience of salicin as I have had, I would not assert in any- 
thing like a dogmatic manner the full extent of its usefulness. 



TREATMENT. 207 

" 1. We have in salicin a valuable remedy in the treatment of acute 
rheumatism. 

" 2. The more acute the case, the more marked the benefit produced. 

"3. In acute cases its beneficial action is generally apparent within 
twenty-four, always within forty-eight, hours of its administration in suffi- 
cient dose. 

"4. Given thus at the commencement of the attack, it seems sometimes 
to arrest the course of the malady as effectively as quinine cures an ague, 
or ipecacuanha a dysentery. 

" 5. Belief of pain is always one of the earliest effects produced. 

" 6. In acute cases relief of pain and a fall of temperature generally 
occur simultaneously. 

" 7. In subacute cases the pain is sometimes decidedly relieved before 
the temperature begins to fall ; this is especially the case when, as is fre- 
quently observed in those of nervous temperament, the pain is propor- 
tionately greater than the abnormal rise of temperature. 

" 8. In chronic rheumatism salicin sometimes does good where other 
remedies fail ; but it also sometimes fails where others do good." 

Writing in 1881, he further says : " Subsequent experience and more 
extended observation have necessarily led to a fuller knowledge of the 
therapeutic uses of the drug ; but they have not led me to recall, or even 
to modify, any of these conclusions." " The patient, of course, is confined 
to bed ; the bowels relieved by medicine, if necessary, and the diet is 
light and simple, consisting mainly of milk and farinacese." "The 
salicyl treatment should be begun as soon as possible ; for, in the 
interest of the heart, every hour is of importance. Twenty to forty 
grains should be given every hour, till there is decided evidence of its 
action. It will generally be found that before an ounce has been taken 
there is a marked improvement. With the continuance of the remedy 
improvement progresses ; and often within twenty-four, generally within 
forty-eight, hours from the commencement of treatment the pain is gone, 
and the temperature is at or near the normal standard." "As the symp- 
toms decline the dose may be diminished ; but it is well not to do this 
too quickly or too early ; for if the remedy be omitted too soon, or given 
in inadequate dose, the symptoms are apt to recur. The object in view is 
to keep the system persistently under the salicyl influence." Treated thus 
the course of uncomplicated acute rheumatism is arrested, the pain is abol- 
ished, and permanent convalescence begins frequently within twenty-four, 



208 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

and generally within forty eight, hours of the time that treatment com- 
mences. In first attacks, and in young subjects, such is almost invariably 
the course of events when there is no cardiac complication. 

" How different from the duration of the disease under other methods 
of treatment ! Under all of them it was common for the acute symptoms 
to last for three or four weeks, and twice that time frequently elapsed 
before the patient was free from pain, or able to leave his bed. Now it is 
often difficult to keep him in bed for more than two or three days." 

Salicylic Acid. — Before considering the mode of action of salicin, and 
the results and the judgment which others have obtained and maintained, 
let us glance likewise at salicylic acid, which belongs to the same group, 
and which in many respects is similar to the former drug. 

This acid has been known since 1844, when it was prepared from the 
oil of winter-green. Its scarcity and great cost prevented its use, and its 
quality remained to a great degree unknown. Through subsequent dis- 
coveries, especially in 1852 and 1869, it became better known, and finally 
in If 73-74, by still further improvements in the process of manufacture, it 
became possible to produce it cheaply. Kolbe in the latter year showed 
its antiseptic properties, and Professor Thiersch, of Leipzig, employed it in 
the treatment of wounds, substituting it for carbolic acid in the Lister 
method. 

Subsequently, for surgical uses, salicylic acid was very extensively em- 
ployed, and is yet to some extent, though now nearly relinquished. 

Then came the application of this remedy and some of its salts in vari- 
ous febrile diseases as an antipyretic agent. Its antipyretic value is ac- 
knowledged in cases of pneumonia, typhoid fever, scarlatina, pleurisy, and 
phthisis ; but by most it is regarded as inferior to quinine, and in the 
acute diseases the remedy shows no power of essentially altering the 
course of these diseases or of modifying the local process. 

Strieker was the first who, in Traube's clinic in Berlin, 1876, used 
salicylic acid in acute rheumatism. His work and Maclagan's with sali- 
cin were entirely independent observations ; and both seem to have 
arisen in answer to the newly worked idea in medicine of the germ theory 
and its teachings. Buss and Kiess had both published, a year previously 
to either Maclagan's or Strieker's publications, the effects of salicylic acid 
in acute rheumatism as an antipyretic medicine ; whereas both Strieker 
and Maclagan were controlled by theoretic considerations, and their domi- 
nating ideas were on the germicide theory. 



. 



TREATMENT. 209 



Strieker's conclusions are given as follows : 

First. — Salicylic acid appears to be a rapid and radical remedy in re- 
cent cases of genuine acute rheumatism of the joints. 

Second. — It is not injurious to the human organism when administered 
every hour in doses varying from seven and one-half to fifteen grains. 

Third. — It can be given in these doses for a longer time to young and 
strong individuals than to the old and feeble. 

Fourth. — In the latter it produces toxic symptoms more readily than 
in the former. 

Fifth. — The toxic symptoms vary in degree. 

Sixth. — Those most commonly met with are noises in the ears, diffi- 
culty in hearing, and diaphoresis ; when these occur, the administration 
of the medicine should be discontinued. 

Seventh. — If salicylic acid be found to fully answer the expectations 
entertained regarding it, the internal administration of a certain quantity 
may be expected to prevent the occurrence of fresh attacks in hitherto un- 
affected joints, and also secondary inflammation of serous membranes, 
especially the endocardium. 

Eighth. — To prevent relapse the medicine must be continued in 
smaller doses for some days after the termination of the main treatment. 

Ninth. — Salicylic acid is of doubtful utility in chronic articular rheu- 
matism. 

Tenth. — It is not likely to be of use in gonorrhceal or diarrhceal rheu- 
matism, or in the polyarthritis attending septicemia. 

Salicylate of Soda. — In respect to salicylate of soda, which is now used 
as much, if not more than the acid, there seems to be no essential varia- 
tion in the effects of the two preparations. 

The similarity of the reports of these two independent observers of the 
effects in this disease of these two closely allied remedies is very striking. 
And if but the half of these observations were true, the millennium of 
rheumatic sufferers would certainly have arrived. 

Numerous observers in this country and in England reported nearly 
equal success, and coincided with the conclusions here given. And now 
the salicic treatment of acute rheumatism, including the use of salicin, 
salicylic acid, and salicylate of soda, was fully launched in the medical 
world and has now been tried by every one, and very largely praised. 

Forty years ago, when Furnival first proposed the alkaline specific 
treatment of rheumatism, there were but few medical publications, and 
14 



210 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

the common mind of the profession was slow to receive new indications 
in respect to either pathology or treatment, and hence but little furor 
could be created about his results. Nowadays the mail steamer carry- 
ing the clinical reports of Strieker's work in Berlin, brought also the sup- 
ply of medicine to every country to which the news was carried, and 
every clinician is at work immediately testing the results. An announce- 
ment in a medical congress is now telegraphed around the world, and 
some conclusion is arrived at in countries thousands of miles away before 
the delegates have dispersed and arrived at home. 

The reception given to the alkaline treatment on its announcement 
thirty or forty years ago, allowing for the greater slowness of communica- 
tion, resembles so much that now accorded to the salicyl compounds, that 
one cannot but pause and reflect, make a comparison, and wonder what 
will be the fate of the new remedies forty years hence. 

Their application arose, so to speak, at dictation of the terms of the 
germ theory, just as the alkaline treatment sprung from the now fallen 
lactic acid theory. And I think that the salicyls will stand or fall as 
stands or falls the test that will be soon applied to the germ theory. 
We would not be without alkalies in meeting indications in rheumatism, 
and so it will probably be in respect to the salicyl compounds. 

Mode of Action of the Salicyl Treatment. 

Now that we have seen the favorable reports of the effects of these 
remedies in this disease let us look to their mode of action. 

Action ofSalicin. — -'First in regard to salicin. It is a crystalline, bitter 
substance, having various therapeutic as well as other analogies to quinine. 
It is only slightly soluble in water. It may be transformed by the use of 
reagents into many of the other members of the salicyl group. Ad- 
ministered internally, it has long been known to have slight tonic proper- 
ties, to act as febrifuge or antipyretic ; hence one of its analogies to 
quinine, for which it has been used as a substitute. Of its general effects 
or of its mode of action we know nothing. If we believe that intermittent 
fever is produced by germs, then quinine acts by destroying the germs, 
and as Maclagan would have us believe, salicin acts in rheumatism as a 
germicide also. 

Taken into the system, salicin is converted into some one of the other 
members of the salicyl group — it is generally believed into salicylic acid. 



TREATMENT. 211 

Thus, according to Senator and other observers, salicin when acted on by 
various organic ferments is changed immediately while in the stomach 
into one of its coDgeners, and that this substance on its absorption into 
the blood is oxidized into salicylic acid. This latter substance makes its 
appearance in the urine within a half hour of the taking of the salicin. 

This conversion of salicin in the blood into salicylic acid is denied by 
Maclagan, claiming that the difficulties of this transformation are too 
great to be effected in this manner. He also denies the accuracy of the 
test by which Senator, Eanke, and others propose to show the presence of 
salicylic acid in the urine. This question has not as yet been decided, and 
the urine reaction shows so far only that some change is effected in the 
salicin on its passage from the mouth to the bladder. What this change 
is precisely, what effect it has on the system, and what effect it has on the 
diseased condition, has not been pointed out. 

Salicylic acid is a very disagreeable, irritating substance when inhaled or 
applied to the mucous membrane. It occurs in needle-like crystals, which 
dissolve freely in hot water, but only slightly in cold. The acid rapidly 
appears in the urine, and passes with that excretion entirely unchanged. 

Senator concludes that salicin acts in fundamentally the same man- 
ner as salicylic acid, since the former is converted into the latter dur- 
ing its passage through the organism. Maclagan argues strenuously 
against the fact that salicin owes its therapeutic virtues to its conversion 
into the acid, and in support of his view quotes the results of clinical ex- 
perience. That salicin has properties that salicylic acid does not possess 
may be taken for granted ; but that it acts in the same way — whatever 
that action may be — on the rheumatic process seems to be pretty certain. 

In judging of the relative value of these two compounds there are 
several things to be borne in mind. First of all, the use made of salicin 
is much less extensive than that of the acid, and with our deficient ex- 
perience there is consequently less knowledge of possible unfavorable, 
dangerous or defective results from its administration. Secondly, a 
natural product, like salicin, is much more likely to be pure, or at least 
to contain matters which are in themselves harmful, than a manufactured 
article like salicylic acid, derived from the source which it now is. 
Thirdly, the former is nearly certain to be a stable compound, while the 
latter, perhaps not even containing a residuum of matters used in its man- 
ufacture in themselves harmful, may, by defective reactions, not be the 
precise molecular body which it purports to be. 



212 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The first difficulty in this category can only be overcome by further 
tests of the relative merits and defects of the two remedies. The use of 
salicin in the large doses recommended has not yet been extensive, 
though many have reported as favorable results as those obtained by Dr. 
Maclagan. This author says, " The only unpleasant effects which I have 
found follow large doses of salicin, are tinnitus, partial deafness, and head- 
ache, such as frequently result from the administration of quinine." The 
advantages of its use, as stated by him, are its equally prompt action, its 
tonic properties ; " that cases treated by salicin are less debilitated at the 
end of the attack, and convalesce more rapidly," that it produces no 
nervous synrptoms, except those noted above, and that it has no disturb- 
ing effects on the heart or circulation. Salicin also has the advantage 
that it " may be freely administered while the system is still depressed 
from the toxic action of the salicylic acid, and that under its use the rheu- 
matic and the salicylic symptoms both disappear." 

Senator, in a review of the whole subject comparing the relative merits 
of the two medicines, concludes that the antipyretic qualities of salicin 
are less marked, and that it is slower to depress the temperature, but that 
its effects in this respect are more lasting. This drug is less likely to 
affect unfavorably the circulation, and hence in the presence of any cardiac 
disease, especially fatty changes in the heart-muscles, it is free from 
danger. 

Many writers have confirmed these advantages of salicin over salicylic 
acid, and the former is generally regarded as free from any unpleasant or 
alarming effects ; but it is thought to be less powerful and more uncertain 
in producing the results desired. It is more soluble than the acid, but is 
less readily dissolved than salicylate of soda, and is therefore less easy of 
introduction in the system than the latter. It causes almost no local irri- 
tation, and is almost always retained by the stomach without producing 
nausea and vomiting. 

Salicylic acid and salicylate of soda are regarded as identical in their 
action. The difference in the two preparations in respect to the amount 
of the free acid is about 1 of the former to 0.68 of the latter, and usually 
a variation in the quantity given per dose is regulated accordingly. 

The preference is now pretty generally given to the sodium salt, on 
account of greater solubility, its less irritating qualities, and its less dis- 
agreeable taste. 

Its effects, as given already in Strieker's summary, are now generally 



TREATMENT. 213 

acknowledged. The differences of opinion which exist are in respect to 
its toxic effects (which are now pretty well recognized), and also concern- 
ing its curative action on the rheumatic process, that is, if we may so 
describe it, its destructive action on the rheumatic poison. 

In respect to its toxic effects — the alarming and dangerous symptoms 
which sometimes supervene in the course of its administration in the 
doses in which it is recommended have been frequently observed and well 
recorded by numerous writers. Some of these effects, especially those 
recorded at the commencement of its use, were undoubtedly due to the 
impurities or the imperfect manufacture of the remedy, and even yet it is 
necessary to guard against dangers from the same cause. Nevertheless, 
alarming conditions are frequently seen from the use of the pure drug, 
and which, if not averted by treatment and the cessation of its adminis- 
tration, threaten disastrous consequences and death. 

Nervous symptoms, similar to those recorded from the use of salicin, 
are pretty frequently met with. In addition to these, delirium is spoken 
of as occurring, but it does not seem to be of a very marked character. If 
proper watchfulness is exercised on the effects of the remedy, the danger of 
the occurrence of this condition can be averted by stopping the use of the 
drug. The cause of delirium has been supposed to be the failure of its 
excretion by the kidneys, and the consequent super saturation of the sys- 
tem by accumulation of it in the blood. Attention to the renal secretion 
and the chemical examination of the urine at the outset of the administra- 
tion, would at once settle the question of the propriety of its use, and its 
continued use can then be determined by its effects. The occurrence of 
delirium I have never seen which could be fairly attributed to the drug, 
while the minor nervous phenomena I have witnessed daily. 

The chief source of danger is the effect of the salicylic compounds on 
the circulation. They are a real source of danger. They are not evi- 
denced plainly by striking phenomena, as are the nervous symptoms, and 
are not complained of by the patient, often until an advanced stage of 
development. They require for their detection a careful examination, a 
knowledge of their character, or a familiarity with the physical status of 
the patient. This depression of the circulation I have seen develop so 
gradually, the patient meanwhile becoming more comfortable, that the 
condition was easily mistaken for improvement. And it is only by a care- 
ful examination of the heart that the weakening of the cardiac action is 
discovered. In such cases I have not found much alteration of the radial 



214 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

pulse, at least not such changes in its character as would warn one of the 
coming or existing danger ; the softness of the radial pulsations, under 
these circumstances, could be interpreted as an improvement, and are 
quite compatible with the ease and comfort felt by the patient. I have 
found that the pulse, by no means in all cases, and not even in many cases, 
becomes increased in frequency, and neither does it have the feebleness of 
the failing, frequent pulse of the exhausted patient. 

In such cases, at the moment we are congratulating ourselves on the 
relief of the patient, another dose of the remedy may place us on the 
brink of a serious or fatal depression of the cardiac action, especially if 
this organ has deformity of its valvular apparatus or fatty changes in its 
muscular fibre. 

The changes in the action of the heart which I have noticed in these 
instances of depression are a feebleness in the apex-beat as felt by the 
hand, an absence of the tone or volume of the sounds as heard by the ear, 
and a general lagging of its contractions. 

Oftentimes the patient commences to complain of a depression or sense 
of sinking before any depression of the heart's action can be detected by 
the observer. This is a full warrant for stopping the medicine and pursu- 
ing another line of treatment. However, with some patients the first dose 
of the salicylate compounds produces nausea, which in many is accom- 
panied by a feeling of extreme sinking, and this false depression passes 
away, as by cqntinuing the medicine the stomach tolerates its presence, 
and the nausea ceases. If we can distinguish the second form of nausea, 
we are warranted in continuing the treatment, in hopes of having the 
stomach retain this desirable drug. I have noticed that the cardiac de- 
pression produces a sinking feeling, which pervades the body generally ; the 
depression of nausea and the sinking sensation is confined to the epigas- 
trium but I do not think this rule is universal. The danger of the remedy 
consists in the possibility of grave dej)ression coming unconsciously to the 
patient, or even with a sense of comfort. 

There is another form of depression seen occasionally in acute rheu- 
matism treated with the salicylate remedies which I do not think ought 
in fairness to be attributed to the toxic agency of the drug. It is a con- 
dition of affairs which is seen in some cases of both intermittent and re- 
mittent fevers treated with quinine. It is also seen in many cases of 
other continued fevers at the period of their crises ; in typhoid fever last- 
ing through the third week, three or four days before the temperature 



TREATMENT. 215 

curve finally descends to the normal it is very common to find the tem- 
perature fall often in the course of a few hours to a subnormal level, and 
with .this comes a condition of collapse. Other fevers exhibit this, but to a 
much less marked degree than typhoid, and in none of them do we fear evil 
from it. In rheumatism untreated, and even with most remedies, we see 
nothing of the kind ; but in giving salicylic acid, so strong is its antipyretic 
action, whatever may be the cause of this, that occasionally we see the 
same result produced, and manifestly it must be regarded in the same 
light. If the condition become too pronounced we treat it, as in typhoid 
or other fevers, by very mild stimulation, or perhaps better by concen- 
trated nourishment. 

The grave depressions of cardiac action due to the toxic effects of the 
salicyl remedies require prompt and energetic means to combat them. I 
have found brandy the best remedy, but black coffee serves well ; and as 
with this depression, and really a part of it, free action of the skin takes 
place and the surface becomes cold, a warm blanket and external heat are 
good adjuvants to the internal remedies. 

Action of Salicylic Acid. — Let us now speak of what seems to be the 
mode of action of salicylic acid. It has not been possible to give any ac- 
count of the physiological action of salicin, since no observations have 
been made with accuracy, and no record of its effects has been made be- 
yond its somewhat slightly tonic ones, and the effects which it produces 
in rheumatism and intermittent fever. 

In regard to salicylic acid we know a little more, and having reviewed 
its effects in rheumatism and seen its danger, we are better prepared to 
understand what is ordinarily spoken of as its physiological effects. In 
speaking of the effects of salicylic acid, we will include those of salicylate of 
soda, which appear to be exactly the same. This salt was proposed for 
medical use by Mceli, of Kostock. 

The first experiments were performed by Koehler, who published his 
account in the Centralblatt fur Wissenschrift Medicinische, 1876. He in- 
jected the drug into the veins and found that the blood-pressure was less- 
ened ; this effect was in proportion to the dose. The pulse at the same 
time decreased in frequency. The same phenomena he found occurred 
after section of the pneumogastric nerves of the spinal cord, which seemed 
to indicate a direct and special action of the drug on the ganglion appa- 
ratus of the heart itself. There seemed to be also a decrease in the respira- 
tory action, and the subjects of the experiments died of asphyxia. This 



216 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

seemed to result from a diminution of the excitability of pneumogastric 
nerves perhaps, resulting in insufficient oxygenation and the accumulation 
of an excess of carbonic acid. 

Action of Salicylate of Soda. — In a memoir to the Academie de Medecine 
in 1877, Dr. Laborde concludes that " the physiological action of salicylate 
of soda is predominantly shown in an elective manner, as it were, on the 
phenomena of the sensibility to pain, or consciousness." " The mechanism 
of this action resides, he thinks, in the influence exercised by the chemical 
substance not only on the conductive power of the sensitive nervous cords, 
but on the receptive centre and elaborator of the peripheric impressions." 
"This action of salicylate of soda on the functions of sensibility, and con- 
sequently on the cerebral organic seat of this phenomena, is the reason of 
the effects induced on the painful symptoms in disease, and it is principally 
as an analgesic that the drug acts in the cure of articular rheumatism." 
(DeseiUe : Thesis, Paris, 1879.) 

In the same year we find numerous communications to the French 
Academy from Professor See? His results are obtained from clinical sources 
alone, and are as follows : 1st. The rhythm and the number of the cardiac 
pulsations remain normal. 2d. In healthy people no modification of tem- 
perature is found, and in some exceptional cases the use of salicylic acid 
has even raised the temperature to a febrile level. In febrile conditions 
its febrifuge power is the most limited and the most doubtful. 3d. The 
respiration is not compromised by moderate doses. 4th. Finally, in 
doses of 6 to 10 grms. daily, the patient suffers buzzing in the ears, a sort 
of deafness, sometimes a staggering, or rather an uncertainty in walking^ 
but never is the sensibility modified in a constant manner, nor are the 
reflexes. 

Bochefontaine and Chabert conclude from their experiments that at 
first the salicylate acts on the brain and the medulla, the organs of sensi- 
bility and motility ; then on the cord and the reflex phenomena ; next, 
on the peripheric nerves and those of excito-motor action ; finally, on the 
movements of the heart and on muscular contractility. In other words, 
its first effects are seen in lessening the activity of the encephalic gray 
matter, and probably also the gray matter of the cord, and that thus it ex- 
ercises a special paralyzing action on the sensitive nervous fibres of the 
peripheric nerves. They also note its effects in producing nausea, vom- 
iting, and diarrhoea, sometimes these discharges containing blood. There 
is also a state of general feebleness, a more or less complete paralysis of 






TREATMENT. 217 



movement, sometimes convulsive movements, and death comes from the 
arrest of respiration and the cessation Of the heart's action. 

Other French experimenters have noted the vomiting and diarrhoea 
often streaked with blood, probably due to the irritant action of the drug 
on the mucous membrane. They have noted the action of the drug on 
the respiratory centres, and its effect in reducing the temperature at least 
1° C. in the non- febrile condition, and a lessening in the frequency of the 
pulse. The urine, too, becomes lessened in amount, and an albuminous 
condition of its secretion is developed. 

These observations are somewhat contradictory, and are not sufficiently 
definite for us to conclude with certainty on the action of salicylic 
acid in the normal condition, or to determine the nature of its effects in 
acute rheumatism. All the reports, however, in a general way, point to 
the facts that, by a paralyzing or depressing action on the nervous centres 
or on the peripheral fibres, or both, it lessens the activity with which tissue- 
changes take place. 

Having given the account of the effects of these two medicines on the 
normal organism, and also their effects in controlling the disease, it is 
proper to consider what is their mode of action upon the morbid state. But 
in order to reach a clear conception we must definitely state in what con- 
sists the rheumatic process. Heretofore our conceptions of the pathology ... 
of this disease have rested under the blackest cloud of traditional notions 
handed down from the earliest times. Finally, the conception of a dis- 
tinctive "rheumatism" freed itself from a medley of other conditions 
having somewhat similar symptoms, but there remained attached to it 
the unfortunate name showing its Origin, and constantly misleading our 
pathological notions of its real status. The name will probably always 
remain. 

Then came a chemical age in which the product was mistaken for the 
cause, and the lactic acid theory held us in its fetters for forty years or 
more. The insufficiency of this theory was not so much disproved as that 
without any one stretching forth a hand to tumble it over it sank out of sight. 

To-day we stand in the presence of a germ theory, and every disease 
is completely furnished out with its own particular zoology or botany — in- 
sanity almost alone stands as an exception — and this malady, according to 
past notions, should have been supplied first of all. The rheumatic humor 
of early times, and the lactic acid of more recent periods, the rheumatic 
poison in general has been displaced by "a minute organism." 



21 S RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

If it is not too late or too old-fashioned already to protest against this 
so-called new idea now is the time, before the peculiar " minute organism " 
of rheumatism has been identified. These views on the nature and action 
of minute organism remind one strongly of the old theological notions of 
pathology looked at, as is the custom nowadays, with a microscope. The 
theologians, who controlled medicine in former times, taught that most 
diseases — and insanity stood at the head of the list — were due to the pos- 
session of the devil or of some evil spirit, which entered the system and 
took up its residence there. The symptoms of disease were owing to 
these perturbing influences. 

The size of these successors of the evil spirits has, in accordance with 
our methods of study, been reduced to microscopic size. We are taught 
to believe that every microscoporon found in our blood or tissue is a 
peculiar germ productive of the disease in connection with which it is 
found. 

The evidence as it stands is quite as strong in favor of the minute 
organisms serving the function of scavengers as that they produce the 
disease. The whole scene of life, as we see it around us, conveys but one 
idea — that life and growth and activity tend to sweetness and purity, and 
not to foulness. In higher life the lower orders take the offal from those 
above them ; the eucalyptus tree renders the stagnant swamp fresh ; the 
maggot in the putrid mass leaves it sweet and clean. 

Without pursuing this idea further, it suffices to state that the pro- 
poser of the salicyl treatment endeavors to saturate the system as thor- 
oughly and rapidly as possible in order that the minute organisms may be 
completely destroyed. 

It seems possible to explain the curative effects of the salicyl compounds 
without calling up the presence of unknown organisms with the pros- 
pect of rapid death before them. It is possible to think of disease, not as 
a foreign entity which takes up its residence in our tissues, producing dis- 
turbance and destruction by new and foreign method. It seems much 
more likely that disease is a misdirection given to our normal functions 
by agents other than minute organisms. We have been accustomed to 
think of disease as changed, depressed, or exaggerated function, but still 
always to be recognized as function, and not to think of medicine as a fer- 
ret sent in to hunt out and destroy an interloper in our bodies. We have 
always sought to think of medicine as guiding the formative and retro- 
grade processes of nutrition according to the normal physiological 



TREATMENT. 219 

methods, and by changing the nervous action or influence to alter the 
blood-supply, which is the fountain of nutritive activity, normal or patho- 
logical. 

So it would seem to be in rheumatism. If we may even in slight de- 
gree trust in the evidences of the experimental effects of salicylic acid, or 
of the results obtained clinically, this remedy causes a cessation of the 
rheumatic process by controlling the misdirected process of nutrition. 
Whether it does this by its action on the central portions of the nervous 
gray matter, or on the peripheral fibres, or on the intermuscular ganglia 
of the heart, thus directly, as it were, altering the blood-supply, or by a 
combination of these effects, we are not able to determine. It would 
seem that, in some cases at least, that the latter of these effects is the most 
pronounced, since it is not infrequent to observe a cessation of the gen- 
eral febrile excitement of the circulation without a corresponding propor- 
tionate diminution of the articular inflammation. And then, too, after the 
discontinuance of the drug, the articular, disease is apt to return — a so- 
called relapse — without a corresponding return of the circulatory excite- 
ment. It looks as though the normal function had returned completely 
to one part and continued normal, while at another part the balance was 
not completely restored. 

Anesthetic and other Topical Applications. 

The value of local applications to the inflamed joints has been very 
variously estimated ; by some as useless, by others as serviceable, by 
others as harmful. None of tliem are probably efficient in removing or 
preventing a return of the disease, but nevertheless probably many of those 
proposed are of use in modifying the local inflammation. The question 
is to be judged of on general principles. 

The list of remedies which have been used for this purpose is almost 
endless, and their effects are generally indicated by the nature of the arti- 
cle employed. And the nature of these articles have been of the most op- 
posite and contradictory characters. The softest of down and the hardest 
of immovable bandages have been applied, the coldest of refrigerants and 
hottest of stimulants or actual heat have been used. The most soothing 
lotion and hypodermic injections of morphia have found their opposite in 
similar injections of carbolic acid and pure water. Leeching, scarifica- 
tion, and blisters have all found advocates. The swollen joints have been 



220 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

nibbed and moved, and they have been compressed by contractile ban- 
dages or fixed immovably by splints. The joints have been treated, accord- 
ing to the varying pathological views of the disease, by salines to overcome 
the acidity, and by carbolic acid and salicylic acid to destroy the minute 
organism. 

The governing principle in the local treatment seems to be this — and 
we know more of the natural history of a rheumatic joint than we do of 
the general disease as a whole — a joint becoming inflamed and swollen is 
painful, and when the swelling has attained its maximum the pain is less. 
The inflammation never or rarely becomes so excessive as to lead to sup- 
puration ; on the other hand, unless the articular disease is of very short 
duration or of very slight degree, it will leave at least some temporary 
stiffness, but this generally passes away without treatment pretty 
promptly. If a joint is many times involved, and severely so, if affected 
for a long time with severe inflammation, or if after a severe inflammation 
a milder type lingers in the articulation, the parts within or without the 
joint cavity may become so much affected or suffer such changes of form 
as to be permanently sore, stiff, or even altered in outline. 

There seem therefore to be three indications : First, to assist the loosen- 
ing or distention of periarticular tissues when the pain is severe or un- 
bearable by means of heat and moisture, both of which should be propor- 
tioned as in other inflammations to its severity. The heat and moisture 
may be assisted by anodynes and by other remedies like alkaline lotions, 
which soften the tissues in these cases as well as in others. 

Second. — It is not necessary to treat the inflamed articulations with a 
view of preventing a possible suppuration. 

Third. — If the inflammation is slow in subsiding completely, or if thick- 
ening and stiffness continues, iodine or other similar remedies hasten the 
return to normal conditions. 

For the comfort of the patient the limb may be elevated or fixed im- 
movably, and the joints should be disturbed as little as possible, since 
movements will increase both the local disturbance and also the general 
symptoms. 

Diet and Regimen. 

During the acute attack no solid food can be digested thoroughly, and 
hence the diet should be entirely fluid. Milk and light meat broths are 
all that is necessary. Usually abundance of water is desired, and of t^ris 



TREATMENT. 221 

the effervescing waters are found often most agreeable, and they may be 
taken separately or mingled with the milk, by which they serve the pur- 
pose of promoting its digestion. Others crave acid drinks, as lemonade 
and lime juice. Citrate of potash in solution, toast water, and many simi- 
lar drinks are in demand. Alcohol in any form is, as a rule, disadvanta- 
geous, though craved by and perhaps necessary to some patients who are 
in the habit of using it to excess. 

During convalescence, or even just after the subsidence of the fever, 
light farinaceous articles may be given with advantage, and still later some 
of the delicate meats, until the return of complete digestion and a normal 
appetite makes its appearance. 

The patient with acute rheumatism should be well protected from cold 
air ; but it is quite as important that the bed-covering is not made heavy. 
The sweating, febrile patient is easily overheated and exhausted. In the 
convalescent period warm underclothing is essential, and a neglect of this 
precaution often causes a relapse with very serious developments. Under 
no circumstances should the patient be allowed to get out of bed, and all 
the wants of nature should be attended to under cover. 



CHAPTER XYII. 

CHRONIC ARTICULAR RHEUMATISM. 

Symptoms and Course. — Morbid Anatomy. — Diagnosis. — Treatment. —Local Applica- 
tions. 

Chkonic rheumatism is a term which has been most variously employed. 
By some writers it is used to describe all forms of rheumatic phenomena 
not attended by fever ; by others, for those changes confine^ to the joints 
and their immediate surroundings which show not an active, or but a very 
slightly inflammatory process, excluding the rheumatic symptoms of the 
muscular tissues. It seems best, at least from a clinical point of view, to 
add the word "articular" to the title, because the symptoms exhibit 
themselves almost wholly in and around the joints, although the muscles 
and their connections are very frequently simultaneously involved. There 
is no inappropriateness in the use of this word, since, unlike acute rheu- 
matism, the internal viscera, and especially the heart, show no tendency to 
participate in changes which we describe as rheumatic, or at least such 
changes never exhibit active symptoms, 

Doubtless very many pains and aches and alterations of the joint pass 
under the designation of chronic articular rheumatism which have little or 
no. relation to this disease. Still, I think the formation of a group of ar- 
ticular rheumatism of a chronic variety enables us to differentiate this 
complaint from others of a different nature more sharply than when the 
muscular forms are arranged with the articular in the same class. But 
because of a certain indefiniteness of which the group consists, and which 
also inheres to our notions of it, we are not prepared to abandon it. 
Bather is it the more necessary to prune and garner the various members 
to render the whole more homogeneous. The less pronounced the synrp- 
toms of a malady, the less able we are to be positive in respect to its nature. 

The components of the group of chronic articular rheumatism are 
formed of several classes of cases. After separating all the joint diseases 
of neural origin, the gouty cases, and the instances of rheumatoid arthri- 



CHRONIC ARTICULAR RHEUMATISM. 223 

tis, as well as the surgical cases connected usually with injuries, etc., we 
have left two classes of chronic joint disease which form the bulk of the 
group. First, those which are dependent on results from previous attacks 
of acute rheumatism ; and secondly, those which develop slowly, gradually 
receiving accretions from time to time, until the joint or joints become 
permanently altered in their function and structure. To these two classes 
some are inclined to add the chronic joint changes which are superinduced 
by such maladies as gonorrhceal rheumatism ; and others, those cases also 
which in their earlier stages were looked upon as rheumatoid arthritis, or 
neural arthropathies, perhaps, which ceased to develop, and even other 
maladies which attack the joints. 

Many writers, as already mentioned in speaking of acute rheumatism, 
are disposed to separate entirely all the classes of this group from the 
rheumatic disease, and to consider them as of a purely local nature. The 
grounds for doing so must rest on the opinion that all the changes which 
are to be described are to be looked upon as the results of disease, and 
not as an acting process of disease ; in other words, that the conditions 
which we consider as chronic articular rheumatism are only alterations in 
function and structure produced by past diseases, but which are in them- 
selves inactive, or have arrived at a stage which the changes have ceased. 

The justice of this view depends on facts, both clinical and anatomical, 
which are open to observation and study. If we define chronic articular 
rheumatism as a lower process of inflammation — as a subacute inflamma- 
tion below the grade of the sub-form of acute rheumatism— it is not proper 
to deny to it a rheumatic origin. If we acknowledge that the changes re- 
sult from the repetition of acute attacks, unquestionably rheumatic, the 
disease itself is certainly rheumatic. If changes of the same character, 
attended with the same symptoms, develop slowly, though its activities 
never rise to an acute grade, to deny its relationship is unjustifiable. 

To place this form of the disease in the class of local ailments merely 
because it so very exceptionally develops fever or visceral complications, is 
saying nothing more than that the condition is not accompanied by such 
phenomena, but it is not showing that it is a distinct disease. It is rheu- 
matism, but it is a local form of it ; local because in activity it is of low 
grade, and simply because it manifests no general or visceral symptoms 
does not prove that no changes in the blood or other organs than the 
joints do not slowly and unobtrusively take place. 

This form of the disease, occurring as it has been shown, exclusively, or 



almost so, iu the latter periods of life, may be dependent on the state 
in which the tissues generally involved in rheumatism have been placed 
by advancing age. We can readily understand how the joint tissues arc 
less prone to exhibit acute inflammatory phenomena, and also how, when 
once inflamed, even though but slightly, they less easily return to their 
normal conditions. That a heart valve in age is less liable to acute endo- 
cardial inflammation is even more ready of explanation. 

The disease is very frequently found, however, in those who, earlier in 
life, have suffered froni cardiac or other visceral complications, and these 
past inflammatory changes often form a serious barrier to the restoration 
of the health of the chronic articular rheumatic. But the disease exists in 
patients who have not been crippled by any of these accidents ; in fact, I 
am inclined to think that the most typical instances often are seen in those 
who have escaped such complications, and perhaps also that, numerically 
considered, the larger number of the cases living are without a damaged 
heart or other viscera. Possibly this fact is due to the cardiac cases dying 
before the joint changes become advanced, and thus also the number of 
patients with valvular disease are diminished. 

That the disease follows from the acute form, and is produced by the 
same general causes, show that the malady, though local in its manifesta- 
tions, is of the same general nature. That when the disease develops slowly 
it does not manifest the usual striking symptoms is due to differences in 
the application of the exciting cause, and the receptivity of the patient, 
and the age and stage of nutrition of the tissues. When the development 
comes after acute attacks it results from improper care and after-treat- 
ment, to exposure too soon after recovery, to improper regimen, and it 
may be from injuries or over-exertion, and to the original severity of in- 
flammation which have perpetuated such tissue changes as form a suitable 
anatomical basis for continued inflammatory changes. This relationship 
of primary inflammation to the subsequent tissue changes in and about 
the articulation finds its parallel in very many other diseases. 

The local nature of the chronic articular rheumatism is defended only 
by those who support the humoral pathology views, and who point to 
such specific agents as lactic acid or "minute organism" as the cause of 
the acute form. It is naturally difficult to suppose that a small supply of 
lactic acid or of "germs" remains over, and more or less permanently 
affects only one or two articulations or a single nerve or muscle. Germs 
live and multiply, and are rarely local in their disturbing effects. Look- 



CHRONIC ARTICULAR RHEUMATISM. 225 

ing, however, on rheumatism as a perverted functional activity, the locali- 
zation of the malady and its indefinite prolongation are easily explainable. 

Symptoms and Course. 

The grade of the symptoms presents an infinite variety ; this is modi- 
fied by the duration, the severity, the stage of development, and very espe- 
cially by the mode of life of the patient. Typical instances are seen 
where, by an easy life, the patient is merely conscious, but nearly continu- 
ously so, of having one or more affected joints. The consciousness con- 
sists in tenderness, or pain and aching, either spontaneously or on move- 
ment only, or a stiffness, or all of these combined, and usually with these 
articular sensations there is a radiation from the joint into the tendons or 
muscles of the neighborhood. Under these circumstances the affected 
joint may exhibit to palpation and to the eye little or no change of its 
external characters, and its motion may be but slightly if at all hindered. 

From this slight affection, rapidly or slowly, the symptoms may in- 
crease, and the form and functions become altered in the highest degree 
short of dislocation, although anchylosis may occur. In many cases there 
are periods of more or less complete alleviation of some or all of the 
symptoms, but this is but imperfectly seen in cases where the anatomical 
alterations are well marked. The periods of immunity from symptoms 
vary very greatly, and their time is influenced by the usual rheumatic in- 
fluences, so-called, climate and season, moisture and cold. Exercise, injur- 
ies, and the state of general health, as well as unknown causes, often lead 
to exacerbation of the malady. 

The joints most frequently affected are generally the large joints, 
although the smaller ones are not exempt. The rule in respect to acute 
rheumatism here also prevails, that the most used or exercised ones are 
preferably diseased ; but this rule is not more universal than it is in the 
acute form. 

In some cases the shifting character of the disease is often exhibited, 
but even here the shifting does not occur after a joint becomes much al- 
tered, although its vagrancy is still seen in the other articulations. A 
more or less symmetrical character is also found in many cases, and per- 
haps even more strikingly so than in the acute disease. 

The aggravations of the disease often come suddenly, like a flash, and 

are naturally attributed to a slight strain of the muscles, tendons, or joints. 
15 



220 RHEUMATISM, GOUT, A^D ALLIED DISORDERS. 

The increase of the symptoms may consist simply of greater pain and 
stiffness, though frequently it exceeds this liinit, and the case becomes one 
of subacute rheumatism, attended with slight swelling, redness, tenderness, 
with effusions within and without the articular cavity, and a slight febrile 
movement is evidenced by the thermometer, pulse, and even other condi- 
tions, which are wholly absent froni the chronic articular phenomena. 

These often slight exacerbations, which frequently pass without medi- 
cal care and observation, undoubtedly have the capacity of developing 
visceral complications, and this fact may account for the belief expressed 
by many, that chronic articular rheumatism often produces valvular heart 
disease. If such clinical facts are substantiated, they go to establish the 
essential unity of the two forms of the disease, and to disprove the purely 
local character of the chronic form. 

In speaking of the complications of acute rheumatism the belief has 
been expressed that the localizations were oftentimes accidently developed, 
and that, in all cases of the rheumatic paroxysm, tissue changes were 
present, which are the essential foundation of the precedent condition 
which by accidental aggravations gave rise to the symptoms or physical 
signs which enable us to recognize the facts. In every well marked rheu- 
matic paroxysm the tissue of the heart valves were changed, but not 
always do they become roughened, and thus collect fibrin which produces 
the initial niurraurs. If in acute rheumatism the tissue swells and in- 
flames, but does not collect fibrin, the cardiac valve may subsequently 
undergo deformity, although it has not during any prior stage given the 
physical signs of endocarditis and roughening. 

This development is certainly of rare occurrence in comparison with 
the initial production of a murmur with roughening and subsequent de- 
formity. But if it can be shown to occur it will help in the explanation of 
those cases of cardiac valvular disease, which must be known to all, found 
in patients suffering from chronic rheumatism. I have known cases in 
which no history of a paroxysm could be ascertained, but in which ad- 
vanced valvular disease existed. 

The duration of the disease is exceedingly indefinite. Many of the cases, 
those especially coming after acute rheumatism, gradually pass frorn this 
grade of the joint affection through a more or less prolonged subacute stage 
into an indefinite chronic form. These cases progressively may improve 
until all symptoms cease, and their past existence is evidenced by only 
a little thickening around the joints. This condition is commonly more 



CHRONIC ARTICULAR RHEUMATISM. 227 

perceptible to the patient's than to any one else's senses. Many other 
cases, however, continue indefinitely without signs of improvement ; in 
fact, from time to time, as the intervals of pain recur, become worse. 

A considerable number of instances are known of patients who, having 
suffered many years from chronic articular pains, gradually — and I have 
known them even suddenly — lose all sense of pain, stiffness, or ailment. 
All of the cases above referred to are those instances in which but compar- 
atively little alteration has taken place in the joint or its surroundings. 

In the larger number of cases — although this number, I am inclined to 
think, is not as large as usually represented — a condition of thickening of 
the capsular and other ligaments, as well as the cartilage perhaps, is per- 
manently altered, and the sufferings of the patient are terminated only by 
life. This termination may come as the result of other rheumatic visceral 
disease, or from other maladies disconnected with the rheumatic process. 
These permanent alterations unquestionably may keep up the impeded 
function of the affected articulation, and it is difficult to determine where 
to draw the line between a rheumatic inflammation and its deformity. 
When, however, the pain and the evidence of the very lowest grade of in- 
flammation ceases, we may conclude that the rheumatic process has ceased. 
We know that a very much altered joint will in time accommodate itself to 
great changes, and will again function comfortably and conveniently, al- 
though its external appearances are deformed and clumsy. 

Morbid Anatomy. 

The cavities of the affected joints are never found to contain more than 
the usual amount of fluid, unless a subacute condition has supervened just 
previous to death, on the chronic changes, and even then the increase is 
not a notable one. More frequently, in fact, I have seen such joints drier 
than normal. The character of the synovial secretion is sometimes altered, 
becoming thicker or more glue-like in character, and to this inspissation 
of the secretion a part of the description of dryness belongs. In addition 
to the greater consistence, the synovia is sometimes no longer clear and 
nearly transparent, but has a slightly yellowish hue, reminding one of the 
color of slightly smoky urine. This color is, I believe, due to blood ele- 
ments, which make their appearance in the fluid owing to the interference 
with the circulation in the synovial membrane and the peri-articular struct- 
ures. The secretion of the joint shows no tendency to become purulent. 



228 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The tissues around the joint — and these are the parts which in my ex- 
perience show the greatest changes in chronic articular rheumatism — are 
thickened and denser in character than normal. The skin shows a vary- 
ing character of changes, none of which are constant or characteristic. 
The subcutaneous connective tissue is increased, its fibres are coarse, and it 
presents the appearance often of cedematous subcutaneous tissue, although 
it rarely allows of any fluid being pressed out from it. The vessels tra- 
versing the neighborhood of the affected articulations are enlarged, and 
this is especially shown by the conspicuousness of the veins, which during 
life are often to be traced by their dark line and the channel they form in 
the sometimes denser skin. 

The capsular ligament loses the shining iridescent appearance of its 
interlacing fibres, and all the ligaments become thickened, dense, and cut 
more nearly like cartilaginous tissue. They have evidently had new mate- 
rial added to them, the result of inflammatory proliferation and by hyper- 
plasia, and the new tissue becomes cicatricial. 

The changes within the joint vary in character according to the severity 
and the stage of the disease. There are two classes of change with which 
I am familiar. The one shows itself as a roughening of the cartilage. This 
roughening consists in ridges and furrows on its surface, so that to the 
sense of touch the once normal smoothness becomes ribbed or fluted ; the 
extent of this change is very varying; in some cases it is wide-spread and 
nearly universal, in others displaying only a few irregular elevated lines. 

In the other class, the articular surface is covered with a layer of 
fibrous material superimposed on the cartilage. In some cases this ma- 
terial forms adhesions between the opposing surfaces ; in others it is free 
from attachments, except perhaps at the margins ; in some cases the ad- 
hesions are short and hamper, or almost entirely prevent, the play of 
movement, and form a more or less partial fibrous anchylosis. 

The cartilage in nearly all cases becomes more opaque and denser 
white, and generally it is thickened. In this form of the disease I have 
never seen erosion of the articular cartilage, but sometimes it is thinned 
where the fibrous adhesions are thick, dense, and well organized, prob- 
ably due to the encroachment of the inflammatory tissue, at one period of 
its existence highly vascular, on the non-vascularized tissue of the carti- 
lage. The cartilage, so far from breaking down, as in suppurative changes, 
tends to become calcareous ; of the constancy and characteristic features 
of the calcification not much can be affirmed, since in so many of the cases 



CHRONIC ARTICULAR RHEUMATISM. 229 

we are dealing with a tissue which from the age of the patient has a nat- 
ural tendency in this direction. 

The inflammatory thickening tends to extend, in well-marked cases, on 
the one hand, to the periosteal surfaces of the adjacent bones, and on the 
other to the sheaths and bursa? of the tendons, and even to the tendinous 
structures themselves, and calcification may make its appearance in both 
of these positions. 

Of the nature, affiliations, and tendencies of chronic articular rheuma- 
tism, examined in the light of its morbid appearances solely, there are sev- 
eral conclusions to be drawn. Nothing in the appearances throws much 
light on the nature of rheumatism — and the same has already been said 
of acute rheumatism — but there is no discredit thrown on their rheumatic 
character, if the pathology of this disease has been read aright. The 
affiliations are all toward the same character of inflammation as we have 
to deal with in unquestioned rheumatism — an inflammation attended with 
a severe, though not high' grade or active class of inflammatory phe- 
nomena—though lasting for a long period the alterations are quite dispro- 
portioned to the symptoms. 

The tendencies are those of a formative character, at least so far as 
this process proceeds, and are aw T ay from the destructive characters seen in 
other forms of arthritis to which the name rheumatism and rheumatoid 
have become attached. And this is quite in accord with the general phy- 
sical status of the patients in whom the diseases respectively make their 
appearance. The chronic articular rheumatisms affect people whose gen- 
eral health otherwise is good, and whose nutrition is well carried on, bar- 
ring the effects of crippling. In the other form of arthritis, the destruc- 
tive process of rheumatoid arthritis, and the general nutritive changes 
start below par, and continue to degenerate. 

Diagnosis. 

The recognition of chronic articular rheumatism is effected without 
much difficulty, from the history of the patient and a close scrutiny of the 
symptoms and course of the disease. In the cases of slow development it 
is probably nearly impossible to say that the condition is not one of some 
of the other articular maladies ; but after a short time its nature becomes 
apparent and the question is easily solved. In cases following paroxysms 
of acute rheumatism the continuation of the disease is self-evident. 



230 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The nature of traumatic and tubercular arthritis should be at once 
recognized by the history, or by the general condition of the patient, as 
well as of the other viscera. The scrofulous disease, at some period at 
least of its development, expresses itself both locally and generally as a 
malady of entirely different type ; it is destructive in its tendencies. 

The forms of arthritis which cause confusion or difficulty in the diagno- 
sis of this disease are certain cases of gout, rheumatoid arthritis, and the 
spinal arthropathies. Gout, mostly a disease of paroxysmal character in 
its articular manifestations, does under certain circumstances lead to de- 
formity and thickenings, attended with pain, discomfort, and inflammation 
of a very low grade affecting one or many joints ; and it is matter of the very 
greatest difficulty to distinguish between these two forms of articular dis- 
ease. Rheumatoid arthritis, besides presenting a different general con- 
dition of the health, shows more joints affected, and pretty rapidly leads 
to deformities. As already alluded to, it is a malady with a different type 
of nutrition. The distinction often spoken of, that rheumatoid arthritis 
does not proceed from an acute attack, is not altogether a very serviceable 
criterion. The differential diagnosis will be recognized after the descrip- 
tion of this disease is familiar. 

The spinal arthropathies nearly always, and usually early in their 
course, present symptoms which no one, unless very careless in ascertain- 
ing their history, could fail to see were indicative of spinal cord disease 
rather than an articular malady. The cerebral arthropathies are at once 
self-evident, or rapidly make themselves known. 

The prognosis is never favorable to complete recovery. Cases do, how- 
ever, become entirely well ; but this is effected more through changes in 
the character of nutrition than from the influence of medication. The de- 
gree of comfort to be obtained is very largely influenced by the circum- 
stances of the patients obtaining for them immunity from unfavorable 
conditions, and very great temporary, or even permanent relief, if combined 
with these circumstances, can be effected by proper hygiene and drugs. 

Treatment. 

Probably the large majority of patients suffering from this disease are 
on foot and about, and a very large element of their treatment consists in 
shielding them from further harm. This is effected by removing them 
from, and warning them against, the causes which develop rheumatism — 



CHEONIC AETICULAR EHEUMATISM. 231 

cold and damp ; for those who have suffered from the malady in any form 
the necessity of over-exertion and insufficient protection by clothing are 
paramount considerations. The methods of enforcing these measures must 
be adapted to each case. 

To all those who discard the rheumatic nature of the disease, and be- 
lieve in its purely local character, the administration of internal remedies 
is regarded as useless, at least so far as such measures are of an anti-rheu- 
matic character. If no rheumatic diathesis exists, there is no purpose to 
be gained in giving remedies whose object is to change or do away with 
the diathesis. But all the same, neither believing in a diathesis, a specific 
poison, nor a minute organism which the remedies are supposed to change, 
neutralize, or destroy, there is great gain to be obtained by internal med- 
ication. 

No one nowadays fails to recognize the fact that processes of nutrition, 
excessive or diminished, or even normal, can be modified by the use of 
drugs. We do not know much of these effects except in a few instances, 
but we seem to be on the brink of finding out a great deal more. Hith- 
erto, in studying the action of medicine, we have been contented with cer- 
tain catchwords which we have accepted as knowledge. We have been 
contented to say a drug was alterative, without being interested in how it 
" altered." When we know whether a morbid process is affected by send- 
ing more blood, or by diminishing the supply to the part, we shall have an 
item of knowledge of the right sort, and be able to influence inflammatory 
actions similar in character to that of chronic rheumatism. In this way 
internal treatment is, and is likely to become, a matter of still greater im- 
portance. By such agencies we may hope to quell local manifestations 
of a morbid process without detriment to normal nutrition, since function 
tends of itself to return to its usual channels and morbid processes are 
more easily affected than normal ones. 

Hitherto various arthritic, rheumatic, or gouty specifics have always, 
been considered essential in the treatment of chronic articular rheumatism, 
and nearly all the lines of treatment recommended for acute rheumatism, 
have been employed with a degree of vigor proportioned to the decreased 
violence of the symptoms. These procedures have returned but little re- 
sults, or have been considered valueless. Colchicum or its derivatives, 
alone of all of them, to-day maintains itself in higher estimation than the 
rest, but it is by no means certain in its effects. The more active the- 
symptoms the better the results obtained from the use of remedies pro* 



232 RHEUMATISM, GOUT, AXD ALLIED DISORDEES. 

posed for the acute form of the disease, and the lower the grade of symp- 
toms the less do our efforts seem to be of avail. 

In addition to these remedies we find recommended, and very constantly 
employed, measures calculated, under ordinary conditions, to improve nu- 
trition and increase the appetite. It is time that many patients, suffering 
from this complaint, have impairment of appetite, take less food than usual, 
and show often considerable emaciation ; but this condition is to be looked 
upon as a secondary effect, the result of confinement brought about by crip- 
pling. Very considerable numbers of patients are, however, well nourished. 
These remedies are appropriate when the general condition of the patient 
seems to indicate them, and they are often essential to improvement of the 
local condition. They cannot, however, be looked upon as specific in their 
action on the local inflammation or the conditions resulting from it. In 
fact, they are often wrongly administered, and fail to do good because they 
cannot be absorbed in the disordered state of digestion so often concur- 
rent with this disease. Nevertheless, cod4iver oil, quinine, and arsenic 
often are most useful The latter is held by some to exercise also a direct 
effect on the articular inflammation. 

Of the remedies recommended in rheumatic inflammation, propylamin, 
which has been used in both the acute and chronic forms, seems often to 
exercise a most striking influence. It will sometimes cause the pains, 
even when severe, to disappear very rapidly, and the swelling, and often 
slight heat of the articulation, are lessened. This medicine, which is 
more reliable in the form of hydrochlorate of propylamin, has a better 
effect in the chronic cases attended with exacerbations than in the slowly 
developed continuous cases attended with deformity and thickenings, 
though even in the latter it is not without beneficial results. 

The iodides, in the form of iodine of potash, are a very universally 
applied remedy. It gives the best results in cases attended with chronic 
thickening and swelling — cases without a tendency to marked exacerba- 
tions—and is to be avoided entirely when any febrile phenomena are devol- 
oped. This medicine is very frequently combined with the bromides, and 
the latter are of great service often when given alone. 

Recently the salicyl compounds recommended in acute rheumatism 
have been used also in the chronic form of the disease. Their effects have 
been reported to be favorable, but their action is less striking anc* jonspi- 
cuous than in the acute malady. In a number of cases I have found 
them of service, but this efficiency is not necessarily to be attributed to 



CHRONIC ARTICULAR RHEUMATISM. 233 

any specific or germicide action. Salicylic acid can be supposed to be a 
drug which, by its action on the nervous system, is capable, under certain 
conditions, of changing the blood-supply not only in the joints but in 
other organs. By this action the perverted function of the rheumatic pro- 
cess may be modified. This drug, like most others, except iodine, shows 
little or no influence in removing the thickenings around the joints, and 
consequently the best results are obtained with it in cases showing active 
phenomena. 

Local Applications. — Kemedies applied over and around the joints have 
received more general approbation than internal medication. Their effects 
are most serviceable, and they are essential and necessary in the treatment. 
Their application is to be directed according to general principles : 1st, 
for the relief of pain and stiffness ; 2d, to promote the absorption and 
removal of inflammatory thickening ; and 3d, to prevent the recurrence or 
continuance of the inflammatory process. 

The haphazard manner in which local applications have been made of 
remedies, recommended as "good for rheumatism," renders the work of 
reducing them to order, and explaining their appropriateness one of the 
greatest difficulty. The method of their use, and the mode of applying 
many very serviceable remedies are so entirely wrong that the object ex- 
pected to be obtained is defeated. Thus an anodyne liniment is often 
rubbed on so roughly as to increase the pain and soreness ; a sedative, 
cooling lotion is applied in such manner as to increase the heat and inflam- 
mation ; and a counter-irritant irritates so deeply the tissues that the swell- 
ing is permanently increased. 

Every one has a favorite remed} r to meet certain indications, and the 
good results obtained are proportional to the skill with which it is ap- 
plied to its appropriate condition. This skill is obtained by experience 
and by a proper recognition of the pathological condition, and a knowl- 
edge of these cannot be conveyed by words. 

Anodyne liniment and morphia, or morphia with atropia, usually suffice 
for the relief of pain, and are indicated when this symptom becomes severe. 
Very often they fail, and a resort to heat and moisture is necessary. This 
may be carried out by wet cloths covered by impermeable sheathings or 
by local or general baths of simple or saline waters. Some one of these 
measures usually suffice to render -the patient comfortable. 

The deformity and thickenings represent two distinct conditions : 
first, the enlargement or swelling due to a very slow and low grade of in- 



234 

flammation ; second, the thickened tissues left behind, which result from 
the inflammatory process. The first is histologically composed of com- 
paratively soft tissue materials and considerable fluid ; the second is 
pretty hard, firm, well-developed fibrous tissue, and these two conditions 
are found mingled in every degree of variety, and our success in treat- 
ment depends on the recognition of the preponderance of one condition 
over the other. 

The typical conditions of each of these are to be met by unlike, often 
opposed, modes of procedure. A sub-inflammation rubbed and handled 
becomes greater ; a fibrous tissue has its circulation uninfluenced by heat 
and moisture, and though it may be thus softened it soon becomes as 
hard and fibrous as before. 

The first of these conditions is oftentimes relieved and dissipated by 
iodine and mercurial applications, provided the inflammatory process is 
not of a marked character, as this is then apt to be increased by their irri- 
tation. Their effect is produced apparently in preventing the further de- 
velopment of the new cellular elements into fibrous tissue. The cells 
which pack the tissue are destroyed, or failing to develop are carried away, 
and thus the disturbed function of the circulation is restored to its normal 
status. As long as the circulation is sluggish new formation is continued, 
and hence tends even to increase itself. The influence of iodine as a mild 
counter-irritant is not to be despised even when tissues have become firm 
and fibrous. 

In the softer condition of the tissue the prevention of cell increase and 
development may be arrived at by a different method, namely, by lessen- 
ing the flow of blood to the affected parts. This method may be carried 
out by general remedies which lower the tone of the circulation, such as 
aconite, etc.; possibly the salicyl and other compouDds effect their good 
results in this manner. Or the means may be of a local character ; of 
these firm compression of the limbs, or of a particular joint (where it can 
be done skilfully) has served me the best. An elastic band of rubber to 
the knee joint or to the leg is very useful, and simple bandage to the 
wrist and arm are very comfortable, and in time change the whole charac- 
ter of the disease. Contractile collodion may be used for the fingers. 

In opposition to this latter method is another which at times in this 
softened condition of the tissues serves an equally useful purpose, though 
it probably is more frequently called for in the second class of conditions 
than in the first. Instead of removing the swelling and thickening, the 



;lak rh] 

results of the sub-inflamiaation, by eompi 
.tion of iodine, bi . 

leek to effect t. by mere -ing 

to restore the normal condition by raj.. 

This object may sometimes be brought a;. entry 

by dry heat than Frictions with the dry haa 

but just here we are on the brink of increasing the infiarrn.. rob- 

bing, and all such measures must be advised and 

utmost skill. The counter-irritant method by blis -in 

truth flying blisters— carried successfully 
articulation are frequently seen to be followed by 
They have the great advantage of producing the. 
scribed manner, and if the result d. eem favorable 

discontinued- "When favorable, the surface of the joint over 

ry superficially — th . 
appear like a cicatricial spot, depressed beneath the surroundir , 
removal of el produced by the rheumatic sub-inflammatory pro- 

ving than the:: 
The same effec puncture. T 

more dainty, and its influence more circum-. 

It often s y beautiful results. It is not 

done skilfully itent of pain, even fro:, 

more than compensates the momentary discomfort 
needle possibly p: . ..-.:-. Yr nerve-i. 

the * sned puncturing maintains the vaso-motc: 

results may follow later from cicatricial changes in the de* 

In the hardened condition of the 
ferred to, the surr . 

ence for good or bad, and our rer„ 
vigor and with 

other class of conditions, to have always clearly in mil] 
pect to effect i :x>cL 

Our objec is to soften the firm, cicatricial-iike tissue : 

ments and the surrounding parts, to pre* 
filaments which course through or in their ne:_ 
tissue squeezes very painfully when it shells even ve 
ence of over-; r the changes of damp w« 

by softening it to promote the freedom of movement oi and 



236 RHEUMATISM, GOUT, ATTD ALLIED DISORDERS. 

bones which are concerned in the movements of the affected articulation. 
For the changes in the cartilages, when roughened, we can do little except 
wait for time and exercise to promote the accommodation of altered sur- 
faces to each other so that they will again move with freedom and 
smoothness. 

This object can sometimes be effected by one of two methods, or by a 
combined use of both. First, by promoting tissue- change and absorption 
by increased vascularity ; second, failing or abandoning the accomplish- 
ment of the first, to manipulate the tissues into a supple condition to allow 
of a partial restoration to normal activity and movement. 

Dry heat, moist heat, general and local baths, or heat alternated 
rapidly with cold can sometimes be depended on to cause and maintain 
an increased vascularity, or at least a more rapid flow of blood. The 
constant use of counter-irritants, or more properly irritants producing a 
deep and lasting impression, are essential, and frequently the only method 
open to us to reach the desired end. Their use must be intermittent, else 
their effect is simply to drive the blood away. A temporary swelling of 
the parts must be induced and allowed to subside before a renewed appli- 
cation is made. During the interval of subsidence the treatment may be 
directed as indicated for the softer state of the tissues. The remedies pro- 
posed for producing irritation range from a slight vesication through all 
grades to actual cautery, and great circumspection is required in making 
a suitable selection. 

The second method consists in massage, manipulation, and of passive 
and active movements of the joint and contiguous lirabs. These means 
may be employed, so far as possible, simultaneously with procedures 
already recommended, but they should always be used in the intervals 
between such treatment, so that the two constantly alternate with each 
other. In addition to the massage as ordinarily practised, the use of 
oleaginous compounds is especially advantageous. An easily flowing oil 
is better adapted than a thick ointment, and the former may be medicated 
if desired. The use of this means is unquestioned, and its advantages 
have been exemplified in all periods of history, from the Grecian athlete 
to the modern dancing-master. 

This method is too frequently disregarded in the treatment of this dis- 
ease ; its use cannot be too strongly advocated for the purposes for which 
it is indicated, but its practice must be restricted to these, for its value is 
limited to these alone. Hitherto the direction " to rub," so easily given 



CHEONIC AETICULAK RHEUMATISM. 237 

and so little understood apparently, has constantly been doing more harm 
than good ; it has been resorted to to employ the hands and thoughts of 
the sufferer in the intervals between the medical visits, and the patient re- 
sorts to it unadvisedly unless strictly forbidden. 

The opposite of this method, enforced rest by fixed apparatus or other 
means, is distinctly contra-indicated in chronic articular rheumatism, un- 
less the condition approaches an acute stage of inflammation. Active 
movements often are impossible on account of pain, but passive move- 
ments carefully made are better in this condition than long periods of im- 
mobility, and are even serviceable in the relief of the pain. 

The subject of the natural spring waters and baths, which so often are 
made useful in this connection, is a long one, and a mere list of springs 
without special directions for their use would be of slight value. 

In speaking of patients suffering from chronic rheumatism, the direc- 
tions for treatment have been given irrespective of the presence of any 
other morbid condition or visceral complication of rheumatic or other 
origin. Great care is necessary to be exercised in applying many of the 
remedies which have been recommended in cases in which cardiac disease 
exists ; this is especially true of the baths. This complication, through its 
effects on the general circulation, renders many of the local measures abor- 
tive, since it becomes impossible to correct the defective heart's action. 
Pulmonary disease, such as emphysema and chronic bronchitis, which are 
no infrequent accompaniments of chronic rheumatism, are nearly equally 
harmful with valvular disease. Other diseases require to be met according 
to their special indications, but, in addition to these mentioned, no others 
are of constant or even frequent occurrence. 

Another condition which I have frequently met with, I deem it impor- 
tant to mention. I know of no casual connection of it with chronic rheu- 
matism, yet the relief of its symptoms or appearances is so frequently fol- 
lowed with removal of the articular conditions that it may prove interest- 
ing, and it is unquestionably beneficial to the patient. 

The condition forms one of the lesser group of the disease, and by many 
it would unquestionably be banished altogether from among its number, 
thence to find no resting place whatsoever in any nosological catalogue 
and to remain unbenefited. The number of instances of the condition are 
large, but do not come to the attention of the physician, partly because the 
patients think it a small ailment, not worthy of notice (perhaps they have 
been put off on former occasions with directions to use some liniment), 



238 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

partly because its nature has never been distinctly apprehended. I have no 
very satisfactory statement to furnish of its pathology, but of its reality I 
am well convinced. 

It occurs not ^infrequently in those who have suffered from rheumatic 
paroxysms, but also in those who have never suffered in this manner. 
The uncertain pains and stiffness are the same as usual, but deformity or 
thickening I have not seen developed. In all respects, therefore, but the 
latter, it shows its relationship or affinity to chronic rheumatism, and 
hence I have included this statement here, this condition which I 
have found that always goes along with the pains is the very posi- 
tive evidence of an abnormal state of the mucous membrane. Ordinarily 
the patients do not complain of disturbed digestion, and very often no 
symptoms of such disorder can be elicited by close questioning ; they 
usually describe their health as perfect, but perhaps not robust, though 
this may be accounted for by their being past middle life ; it occurs, how- 
ever, early in life also. An examination will show, even if no complaint 
of digestive disturbance is made, that the tongue is coated or dry and 
leathery, that it is swollen and marked by the teeth along its borders ; in 
addition, there is evidence of some sort or other that this condition is pres- 
ent throughout the digestive tract. We have then an instance of the very 
lowest form of a catarrhal irritation, or even an inflammation, so low in de- 
gree, however, that it does not excite the usual dyspeptic symptoms which 
the higher grades always produce. 

This inflammatory condition, vast in extent, though low in grade, we 
may readily suppose is capable of disturbing the functional activity of 
other parts of the organism. That it does on occasions influence the sen- 
sory organs, for example the eye, we well know, and that it may disturb 
the cerebral circulation, producing aural phenomena and the variety of 
vertigo described as gastric, we have ample evidence. Is it less probable 
that it may also produce nutritive changes in and around the joints in 
patients whose point of least resistance is situated in these parts, those 
with the so-called arthritic diathesis ? I think not, and I have found that 
whatever would remove the catarrhal condition banishes the articular 
symptoms, as it does the ocular and cerebral phenomena. 

This suggestion of the pathology of the condition does not, I consider, 
lend a probability to any humoral views of the nature of this complaint or 
of acute rheumatism. In the first place, we have little or no evidence of 
such disorders of digestion as would be productive of noxious matters in 



CHRONIC ARTICULAR RHEUMATISM. 239 

the digestive tract furnishing the materies morbi ; secondly, the relief is 
often so sudden under the treatment to be suggested that no opportunity is 
afforded of purging the blood of poisonous or irritating matters. On the 
other hand, everything about the condition favors the idea of the produc- 
tion of it by tissue changes or alteration of function through nervous 
influences reflected from one position to another. Furthermore, I have 
nothing to offer in opposition to the view which traces both of these irri- 
tative or inflammatory conditions to one common source or seat. 

The means of relief for this condition consists in the endeavor to find a 
remedy or a plan of procedure which removes the catarrhal state of the 
mucous membrane. Many such remedies are found among the numerous 
groups of chloride compounds. Muriate of ammonia, chloride of arsenic, 
and several other of the metallic chlorides are often useful. The best 
results are to be obtained from the mild chloride of mercury given in very 
minute doses and at frequent intervals. The diet requires but little 
change, unless some dyspeptic symptoms are present, or unless the diet- 
ary is manifestly improper. The use of the corrosive chloride of mer- 
cury in still smaller doses (one-fortieth of a grain) and at less frequent 
intervals than the former, has also yielded favorable issues. The effect of 
neither of these drugs can be attributed to their mercurial action, since 
given for a period of a month in the small doses and at very frequent in- 
tervals, even two or three hours apart, no mercurial action is seen to result 
from their use. Mercurials have been recommended for chronic, as well as 
acute rheumatism, but the dose has always been a large one, mercurialism 
has been induced, and the results have not been favorable. In the small 
doses their effects are very different, and nearly always favorable, and 
prompt when the morbid condition does not exist for a very long period. 
No striking symptoms or phenomena are brought about beyond the re- 
moval of the catarrhal condition, and in this instance the relief of the pain. 



CHAPTEE XVIII. 

GONORRHOEAE RHEUMATISM. 

Liability to, and Frequency of its Occurrence— Symptoms, Course, and Duration — 
Its Results — Treatment. 

This disease did not pass without recognition by many of even the 
older writers, but their observations on the subject afford very little infor- 
mation which is useful. Among English writers Cooper was the first to 
so graphically describe it that general attention was directed to it, 
although he was not the first to observe and mention it. It has attracted a 
large share of attention among Erench writers. But from all the very tho- 
rough discussion which it has received at various times very little has 
been added to our knowledge of the malady given in its early description. 

The condition has received its name from the two facts that an 
articular inflammation, not dissimilar to a rheumatic one, makes its ap- 
pearance, and that this inflammation comes on sometimes during an 
attack of gonorrhoea. The frequently observed concurrence of these two 
inflammations led to an establishment of a separate form and to the dis- 
tinction of this articular inflammation froni the ordinary rheumatism. 
Previously the rheumatic phenomena were classed with acute or chronic 
rheumatism according to the grade of its severity, and the urethral dis- 
charge, when not regarded as an accidental or concurrent attack, was 
thought to be a rheumatic localization. In the latter case the rheuma- 
tism was looked upon as the cause of the urethral discharge. 

At present the gonorrhoea! urethral inflammation is regarded as the 
cause of the articular disease, although there is some difference of opinion 
in respect to its mode of action in producing the joint inflammation. The 
majority of observers favor the pysemic mode of causation, and I t hink 
rightly so. Others refer the effects to the results of reflex irritation, and 
many instances have been cited in support of this view. 

The occurrence of the articular conditions does not seem to require 
for its production any of the usual exciting causes which lead to the ordi- 



GONORRHCEAL RHEUMATISM. 241 

nary rheumatic attacks. The mode of life, the circumstances of the patient, 
and the general surroundings, as well as climate, seasons, etc., do not 
seem to have any influence in its causation. A- patient exposed to cold, 
irregularity of habits, and intemperance, may thereby develop an attack 
which otherwise would be escaped, but these or similar conditions are 
not necessary concomitants of its development. 

Men suffer gonorrhceal rheumatism very much more frequently than 
women, and this preponderance is relatively greater than the proportion 
of attacks of gonorrhoea in the two sexes. Women having gonorrhoea show 
less liability to the articular disease, and this exemption has been accounted 
for by the less sensitiveness and greater thickness of the mucous mem- 
brane of the vagina and urethra in women than the urethral tissues in man. 

The period of life during which the disease occurs is limited by 
obvious circumstances ; in men it has been noted to occur shortly after 
the age of puberty, and from this time on until past middle life ; in women 
the cases which I have seen have been in the quite young or those who have 
been abused sexually at the time they have acquired the gonorrhoea. In 
women the vaginitis may be a subsidiary feature of the disease, and they 
may make no complaint of its symptoms. 

The frequency of its occurrence in relation to the whole number of 
cases of gonorrhoea we have no means of determining, though we have 
felt sure the proportion is very small ; some patients develop the rheu- 
matic symptoms on the occasion of each successive attack of gonorrhoea, 
and having once had gonorrhceal rheumatism the articular inflammation 
returns with every urethral irritation or excitement. 

The condition of the general health has probably more influence on its 
development than this circumstance seems to have in acute rheumatism. 
The weakly, debilitated, and exhausted have, in my experience, furnished 
the larger number of cases. The disease is, however, met with in those ap- 
parently in robust health, excepting, of course, the gonorrhceal complaint. 

We have no facts by which to show conclusively the mode of causation 
of the articulation and its direct connection with the specific urethritis. 
The original theoretical explanation of the disease was that the in- 
flammation was transferred from one place to another by metastasis ; but 
this theory has fallen to pieces in reference to every morbid action, and is 
now abandoned. Other theories have been proposed, but have passed- away 
with the hypothetical notions on which they were based ; for example,, 

organic sympathy 
16 



2 ±'2 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The two theories which to-day divide attention are that of reflected 
irritation and the pyaoniic theory. The former of these was proposed by 
Foumier, and was based on his observations that other irritations besides 
the gonorrhceal inflammation developed articular symptoms ; for example, 
catheterism and other inflammations of the urethra of a non-venereal 
origin. Such cases, however, have been very infrequently reported, and 
when they do occur the phenomena, especially the general symptoms, but 
likewise the articular ones, are not typical of the usual cases of gonorrhceal 
rheumatism. Reflex irritations, when such truly occur, are, as a rule, 
promptly developed and usually as promptly subside on the removal or 
lessening of the cause. This result is not the characteristic of the course 
of this disease, otherwise the articulation should come and go when the 
urethral disease had reached its acme. And then, too, while irritations at 
distant parts are seen commonly enough through nerve-channels, inflam- 
mation requires for its production something more forcible — it requires 
irritation at the root or source of the peripheral nerve which is distributed 
to the seat of the inflammation. 

The spinal arthropathies are seen when the irritation is in the cord 
itself, and not under the influence of reflected action. 

The symptoms and course of the disease favor the pysemic theory much 
more strongly than any other. While the phenomena are in accord with 
this view in by far the larger number of cases, the evidence in its favor is 
not without its defects. In the first place, it is very infrequent to find 
pyasmic or septicsemic symptoms of any sort result from a mucous mem- 
brane inflammation, unless such inflammation is very long continued, very 
extensive, or else some purulent depot is formed in the neighboring tissue, 
organs, or lymphatic glands. Secondly, no evidences of a gonorrhceal pyae- 
mic disease in other organs have been pointed out or are known to exist. 
Neither are the articular inflammations widespread or numerous, and the 
changes in joint-structures are by no means typical of pyseniic inflamma- 
tion. Still, withal, the symptoms and their course in the absence of any 
extensive data of the morbid anatomy of the disease seem much better ex- 
plained on this ground than any other as yet proposed. 

In the absence of post-mortem details, it would be quite out of place 
to discuss further the possibility and the method of infection of this pye- 
mic process. Our knowledge of the state of the joints in the early stages 
of the disease is likewise very limited, although the facts, so far as known, 
point to it as an inflammation chiefly affecting the synovial membrane and 



GONORRHEAL RHEUMATISM. 243 

also the articular cartilages. The peri-articular structures seem to be but 
little affected by marked inflammation, although they exhibit often great 
swelling. The inflammatory effusion very frequently shows a tendency to 
fibrinous deposits. In the later stages, the joints sometimes present a 
condition of false anchylosis. The disease therefore belongs to the class 
of arthro-meningo-chondritis. 

Symptoms, Couese, and Dueation — its Results. 

At some time during the continuance of the gonorrhceal urethritis, the 
patient feels a sense of heaviness, aching, stiffness, or sharp pain (the sen- 
sation is variously described) in one or other of the joints. The knee- 
joints are far more commonly the first to be affected, and the records 
show that the left knee is the favorite one, and it is not uncommon for the 
disease to be limited to these articulations, and even to one of them. Any 
other single joint may form the sole localization of the inflammation. In 
some cases, however, a number of joints may be successively involved, or 
all at once at the outset of disease. 

The urethral inflammation and discharge have usually existed some 
days, at least they are well developed, and it may be subsiding before the 
articular disease commences. I have seen a patient among my hospital 
cases, who was entirely unaware of having, or of having had, gonorrhoea, 
and who on admission to the ward was suffering from a monarthral inflam- 
mation of some days' standing. The urethral discharge was pointed out 
to him, and he gave a consistent account of its acquirement twelve days 
before the articular symptoms were noted. A young woman, with an arti- 
cular inflammation, who was unaware of having gonorrhoea, and who did not 
suffer inconvenience from it, gave the history of the probable contraction 
of the vaginal disease, and of great sexual excess at the time of its acquire- 
ment. She had felt local discomfort from the excessive frequency of coi- 
tion, but none of the usual symptoms of gonorrhoea in young women. 

The articular symptoms come without usually any of the common ex- 
posure which precedes acute or subacute rheumatism. And the patient 
frequently tells of waking in the morning with the sensation in the knee, 
or perhaps some other joints, which prevents rising or using of the af- 
fected limb. The sensations increase only slowly in severity, and some- 
times do not increase, and the parts do not at first exhibit any alterations 
in their external appearance. Movement is more painful than is handling 



244 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

of the joint, and the aching not unfrequently extends into the limb, at 
first above the implicated joint, and later below this part also. The red- 
ness, so constant in acute and subacute rheumatism, is often, in fact most 
generally, absent through the whole course of the inflammation. 

The inflammatory process is, throughout its course, of a subacute 
type, and is generally slow in development. It is often many days in 
reaching its height, but it is very much increased and rapidly hurried for- 
ward in its course by movement, especially walking, when the knee is in- 
volved, and pressure in addition to movement is inflicted on lining struc- 
tures of the joint cavity. The swelling is consequently several days in 
arriving at any very noticeable degree of distention of the capsule of the 
joint. While the fluid is increasing in amount, the aching is often intol- 
erable, preventing sleep without anodynes, and is of deep-seated charac- 
ter. This symptom does not seem to cause the same degree of restless- 
ness or other nervous symptoms as is the case often in acute rheumatism. 
The patient is wont to be apathetic. 

The general symptoms in the early stage are usually slight, the tem- 
perature is normal, or but little elevated, and always subfebrile (99° F.). 
I have known the thermometer to indicate 102° F., taken in the axilla, 
on the fourth day of the attack, when only one knee-joint was affected, 
and I have seen it a degree higher when the knee and elbow were simul- 
taneously involved. 

Sweating is generally not a marked feature, but in severe cases, and in 
the debilitated, I have seen it presenting strikingly pyseniic characteris- 
tics. In these cases, too, marked rises and falls of temperature without 
the involvement of new joints, or even an exacerbation of inflammation in 
ones already affected are seen. But this feature is not striking or com- 
mon in the usual cases. In fact, in gonorrhoeal rheumatism, the flitting 
from one joint to another is of rare occurrence ; it never occurs in the 
manner so noticeable in acute rheumatism. The joints, if successively in- 
volved, pursue the inflammatory course irrespective of each other, and lit- 
tle, if at all, modified by the general symptoms. 

The inflammation, when at its height, distends the joint implicated 
often to a marked degree, so that distinct fluctuation is perceptible, and 
if it is the knee-joint, the patella is floated upward. The character of the 
fluctuation apparently varies with the sort of fluid which is present in the 
joint-cavity ; at all events, sometimes the fluctuation is tense, elastic, and 
easily produced, as though the effusions were thin, and at other times 



GONORRHEAL RHEUMATISM. 245 

doughy, flabby, and only slightly perceptible, apparently from a thick, 
sero-fibrinous fluid. Of course these distinctions may be modified by the 
conditions of the coverings of the joint. The skin over and adjacent to 
the articulation is sometimes oedematous, at others, nearly unchanged in 
appearance, and almost never tense, smooth, or shining. 

The articular inflammation runs an indefinite course and may be very 
prolonged, or if the inflammatory symptoms cease the effusion may re- 
main for a long period. It is always of some weeks' duration and it may 
be months before the joint returns to normal conditions. There are two 
unfavorable terminations to the attack : the one where a chronic effusion 
remains long after health is apparently restored, which resists our efforts 
for its removal, the other in which apparently the fibrinous element pre- 
dominated in the effusion, and where as a result great stiffness and even a 
more or less complete fibrous anchylosis results ; the latter condition pro- 
duces great crepitation or crackling on any movement of the limb, and it 
may be perceived on moving the patella with the fingers. The joints show 
no tendency to suppurate, although pus may form in the connective tissue 
in the neighborhood ; possibly the latter is due to injudicious treatment 
or severe and ill-applied remedies, since the inflammation in this tissue is 
rarely severe. The urethral discharge has commonly ceased before the ar- 
ticular symptoms have disappeared, but not infrequently a gleet may remain. 

Recurrence of gonorrhceal rheumatism does not come without the re- 
newal of its cause, and the course toward recovery is continuous though 
slow, and pauses often come with complete inaction. Except through 
imprudence, from inattention or undue disturbance of the joint, the in- 
flammation rarely tends to return after partial or complete subsidence. 
Another attack of gonorrhoea or other marked irritation or inflammation 
of the urethra is perhaps to be regarded as a more efficient cause of a re- 
turn of the articular symptoms than the primary urethritis, or at least 
that the joint once subjected to the inflammatory changes is more likely 
to have its nutritive activity disturbed than prior to such occurrence. Of 
this, however, it is difficult to be positive. 

Second attacks of gonorrhceal rheumatism are probably less common 
than a recurrence of ordinary rheumatism ; possibly because its exciting 
cause can be more surely avoided. When second attacks come they are 
said to be attended with less marked inflammatory phenomena, but the 
joints are more likely to continue longer affected, to be more stiffened and 
even permanently affected than in primary attacks. It is said also that 



246 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

more joints are liable to become involved, even to the disease spreading 
all over the skeleton. Such statements must be scrutinized very carefully, 
and it is certain that in many of the older cases the disease has been con- 
founded with both acute articular rheumatism and with arthritis de- 
formans. The possibility must be borne in mind that some patients, with 
a stronger rheumatic susceptibility, may be suffering the results of illicit 
intercourse and who pretty constantly during the activity of the virile 
function have a gonorrhceal inflammation. 

The secondary localizations of the disease are, unlike acute rheumatism, 
rare. The eye and its appendages may become affected, and this fact oc- 
casionally serves to call our attention to the character of what might 
otherwise be an obscure case of articular inflammation. The eye affection, 
however, seems to be a direct transference or inoculation of the conjunc- 
tiva by the irritant pus from the urethra being carried by the fingers or 
clothing to the palpebral fissure. It does not appear to be an inflammation 
of the sclerotic, such as is seen resulting from ordinary rheumatic causes. 

The other serous membranes do not show a tendency to become the 
seat of inflammatory changes as in acute rheumatism, and the valves of 
the heart do not suffer from endocarditis. Very recently, however, one 
or two apparently authentic cases have been reported of gonorrhceal 
endocarditis. If this fact should be confirmed it would strengthen the 
pyseniic view of the nature of the disease, and if we believe in the pye- 
mic theory we should not be surprised at the occurrence of both the 
endocardial inflammation and of that of the serous membranes. It is a 
fact, however, that these complications rarely have to be combated. 

The diagnosis and prognosis of the disease are sufficiently evident from 
the preceding remarks. The certainty of the former depends on obtaining 
a history, or on the presence of the urethral discharge. The prognosis is 
never unfavorable to life ; even the prolonged duration does not lead to 
fatal or extreme exhaustion. A crippled joint may in time be induced to 
resume its function. 

Treatment. 

We are here presented with two considerations, first what shall be 
done for the gonorrhoea, and second according to what principles shall our 
remedies be directed for the relief of the articular inflammation. We may 
in some cases be called upon to treat the general condition of health. 

In respect to measures directed against the urethral discharge, very 



GONORRHEAL RHEUM ATISM. 247 

frequently the advice has been given to do nothing for it lest the remedies or 
the means of their application serve to increase the irritation of the mucous 
membrane, and thus an aggravation of the articular disease be brought 
about. Surely if this advice is sound we must either doubt the value of the 
remedies in gonorrhoea, or give up in great measure our pya^mic theory of 
the nature of the disease. If this cautious advice means merely that our 
local applications to the urethra or those internally administered shall be 
of such character as not to increase the irritation, the directions ud question- 
ably apply equally in gonorrheal urethritis as in gonorrhoea! rheumatism. 

If we believe that the disease is of pyemic origin, that it is caused in 
some manner by the pent-up discharges of the urethral mucous membrane, 
surely it cannot but be proper to remove the inflammatory condition or 
wash away the discharge. Under ordinary circumstances, patients and their 
physician are desirous of " stopping " the discharge immediately, and reme- 
dies are often exhibited which do more harm than good, but in gonorrhoea! 
rheumatism the urgency is much less, and a mild astringent injection or 
even a simple saline one used with a view to cleanliness generally will meet 
all the indications. The enforced rest in bed is exceedingly beneficial. 

The development of the rheumatic symptoms has not been thought to 
be in any way due to the methods instituted for the cure of the gonor- 
rhoea ; cases occur after all modes of treatment as well as without treat- 
ment ; neither can the occurrence be charged to the neglect of treatment. 
As a practical fact, so many cases of the articular complaint come under 
treatment, both among hospital and private cases, so late in the gonor- 
rhoeal disease that the discharge is lessening and with or without previous 
treatment is disappearing, so that no remedies are required. Frequently it- 
must occur in private cases, that, owing to the inability of the patient to 
attend to himself, to the absence of a proper attendant, or for the purpose 
of concealment, nothing can be done for this inflammation. 

The joint disease does not seem to differ from any other inflammation 
or inflammatory effusion in the cavity of these structures ; it is not a spe- 
cific disease, although it is due to a special cause. The treatment must be 
guided accordingly, and directed to allaying the inflammation, to the pro- 
motion of the absorption of the effusion subsequently, and to the restoration 
of the movements of the joint if they become impeded by adhesions. 

Many things have been recommended, as though they were specific 
remedies, and others have been applied in. so haphazard a manner, or irre- 
spective of the requirements or stage of the inflammatory process, that, 



248 

judging from the records of some published cases, the disease has been 
prolonged beyond the time in which it would probably have recovered 
unassisted. The complaint is a stubborn one most generally, and re- 
quires assistance very judiciously applied. 

Kemembering the disease is an inflammation which, untreated, usually 
runs a moderate course, it does not appear judicious to make use of deple- 
tion, either local or general. The local depletion by leeches flr scarified 
cups is apt to be harmful in the thinly covered joints such as the knee ; 
perhaps in the deeply seated ones, as the hip or shoulder, which, owing to 
their thicker covering can be less easily affected by other remedies, blood- 
letting may find its uses, and for the same reason is less likely to do harm. 
From the use of leeches I have seen both peri- and intra-articular sup- 
puration, and from the use of the scarified cups, both an increase of pain, 
inflammation, and superficial suppuration. Besides its liability to harm, 
the mode of procedure is certainly not frequently required. 

Cold, applied in the form of ice, is likewise not usually indicated. 
Cooling by evaporating lotions is much more frequently serviceable, and 
this may easily be carried out by a lead- water lotion. 

Eest is essential, and the limb should be elevated when this can be 
done, I have found a bed of pillows raised above the bed quite as useful 
and much more comfortable than any fixed apparatus or splint which re- 
quires bandaging. When the shoulder is affected, but little can be done 
by these means, but a pillow, or pillow and splint, is easily arranged for 
the elbow. The knee-joint is much more frequently affected than any 
other, and I have met this indication for it by a light extension apparatus 
attached to the foot and ankle, with the limb properly elevated on the pillow 
and allowed to bend at the knee, since this is the most comfortable posi- 
tion for the joint when an effusion is present in it. The slight extension 
serves not merely to keep the limb quiet during sleep, but also to separate 
very slightly the inflamed surfaces. It is to be recommended as a source 
of ease to the patient; a similar appliance might be found of use when the 
hip is affected. Splints must be used with caution, since their fixation of 
joint favors a false anchylosis, unless their angle is frequently changed. 

An application which has served well in the earlier stages of the in- 
flammation — in fact as long as the inflammatory process continues — is a 
mixture of lead- water and laudanum. The full strength of these drugs in 
equal proportion or slightly diluted with water is to be used. Let a cloth 
or piece of lint be saturated with the mixture, and placed over the in- 



GONORRHEAL RHEUMATISM. 249 

flamed joint. This may be left uncovered, and thus serve as an evaporating 
lotion, but more generally it is well to cover the whole with an imper- 
meable sheathing of gutta-percha. The closeness with which this is 
sealed up can depend on the degree of warmth developed ; if it becomes 
too warm the pain may be increased ; but later, as the inflammation abates, 
a bandage exercising slight pressure can be applied with advantage. 
Under this treatment the inflammation will subside, and sometimes all the 
effusion become absorbed. 

After the inflammation has ceased — it may be a long time — a consid- 
erable effusion very frequently continues present, and is often stubborn to 
treatment. For this condition various measures may be put in force, ac- 
cording to causes which seem to maintain or to continue its presence. Rest 
is just as essential now as at any period, although passive movements are 
often useful or necessary. Iodine in the form of one of its solutions, or 
perhaps as an ointment, mercurial ointment or plaster, the various means 
of counter-irritation, or alteratives and absorbents will find their use. 
Local and general hot water, or vapor or air baths are highly recom- 
mended in some cases. The measures would seem to be more useful when 
the condition was prolonged by a low grade of inflammation. The more 
stubborn cases and the simple dropsies of the joint will rarely resist the 
application of pressure carried out by straps of adhesive or lead plaster, or 
by bandages ; these can be combined with some one of the above remedies. 

I have seen several cases where the local condition seemed to be main- 
tained or prolonged by the feeble or exhausted condition of the patient, 
due either directly to the disease or to previous debaucheries ; sometimes 
the patient is very feeble, even when the joints recover pretty promptly. 
In the former cases it is necessary to attend to the general condition in 
order to insure a favorable result. And in every patient who does not 
exhibit robust health, it is safer, especially remembering the pysemic char- 
acter of the disease, to administer tonic remedies. Quinine and tincture 
of chloride of iron meet these indications, and they should be given in full 
doses. Other symptoms and conditions are to be attended to as they 
arise, according to general principles. 

No case need be abandoned as hopeless, even should anchylosis occur, 
and in nearly all cases it should be prevented from occurring by early and 
constant daily movements of the affected joint. The adhesions, if they be- 
come firm, can be readily broken up under an anaesthetic, and this should 
be done early and thoroughly, and the treatment continued as indicated. 



CHAPTER XIX. 

GOUT. 

Causes and Causal Factors. — Age, Sex, Heredity, Customs, and Nationality. — Vari- 
eties. — Symptoms, Course, and Duration. — Acute Gout, Chronic Gout. — Visceral 
Manifestations.— Pathology and Morbid Anatomy. — Diagnosis. — Prognosis. — 
Treatment. — Treatment of the Paroxysm. — Treatment of Chronic Gout. 

Gout has, in past ages, and even up to recent times, received the greater 
share of attention, and been supposed to constitute the greater bulk of the 
cases forming the extensive arthritic group. From this group have from 
time to time been separated, one member after another, as their character- 
istic differences became recognized. We have seen that rheumatism was 
thus first recognized in the seventeenth century, but more than four cen- 
turies before this disease received the name of gout, and it was under this 
title that all the members of the arthritic group were discussed. 

The derivation of the word is obscure, and I believe the work of the 
author, Budolphus, from which we might have derived information on 
this point, who first used the term, has been lost. Its meaning is to be 
referred to old humoral pathology which taught that the disease was a 
material effused or dropped (gutta) into the joints. 

The nature of gout has been always a question very much discussed, 
and no hotter battles have been fought than about the pathological condi- 
tion which produces it. Passing by the notion of the ancients concerning 
the humors of an uncertain and vague character, which were looked upon 
by them as the cause of all forms of disease, we find that the humoral the- 
ory of the disease has always been the prevailing one, and its factors have 
been presented in many different aspects. The variations in the humoral 
theory have consisted principally in the question whether there was merely 
a retention of the offending material, or whether there was, in addition 
perhaps, an increase in the amount of it produced. 

The opponents of this school of believers have found but few followers, 
and they have presented their views with great cogency. Cullen was the 



GOUT. 251 

one who traced the cause of the disease to changes in organs other than 
those chiefly or most strikingly affected during the paroxysm of the attack. 
Recently, and chiefly through the work of Garrod, the almost univer- 
sally prevalent humoral belief has become confirmed. And it is not strange 
that this theory should so universally receive approval, since in no other 
disease are the phenomena so much on the surface, and after its attack are 
the results so completely placed to our hand as a means of verification of 
the morbid process. So simple does the problem seem that, knowing the 
ways of nature in health and disease, this apparent simplicity is almost 
enough to raise the doubt whether we have actually arrived at a thorough 
solution of the question. 

Causes and Causal Factors. 

The chief etiological factor of gout is the presence in the blood and 
the tissues of uric acid and its compounds. How it is produced, and 
under what circumstances the material is retained in the organism, con- 
stitutes one of the important parts of our studies of the disease. And in 
the first place we must look at what are the favoring circumstances and 
conditions of life, such as age, sex, habit, etc., under which the morbid 
action makes its appearance. 

Age. — Primary attacks of the disease are very much more frequent in 
middle life than before or after this period. There are very few attacks 
before the age of twenty, but such have been reported in young children, 
and after the age of puberty they become more frequent. After the age 
of forty-five and fifty primary attacks decrease in frequency, but they have 
been observed at a very advanced age. The declining period of life fur- 
nishes the greater number of cases of the disease, and this is the age in 
which its development and its changes are the most marked. 

Sex. — Women have gout very much more rarely than men, and this is 
especially true of the articular form with its distortions. And in women 
it has been thought to come on later in life than in men. Some writers 
have explained this fact by the different peculiarities of the sexual organs, 
the maintenance of the menstruation through a long period of their lives, 
which discharge is supposed to shield them from its attacks. Some claim 
that in the majority of cases the disease does not make its appearance 
until after the climacteric period has arrived. 

That men should be affected with gout more frequently than women is 



252 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

evident from the fact that the habits and mode of life which are especially 
productive of the disease concur more frequently in the former than the 
latter. 

Heredity. — By the old authors gout was always spoken of as an heredi- 
tary disease, and by them this was looked upon as the chief cause of 
its production. In fact, gout has been pointed to with more or less pride 
as an heirloom in the family, like a jjiece of plate, and as a disease which 
conferred more or less respectability on its sufferers. "With our more 
democratic notions of the present time, and also the fact that a well- 
marked form of poor man's gout has become known, this pride has be- 
come somewhat lessened. More than once I have had the diagnosis of 
gout given me by a patient in a case of chronic rheumatism, and once, 
where to confirm the gouty nature of the complaint a bastard paternity a 
generation before was confessed, and a relationship with an English 
nobleman was claimed with some pride. 

Undoubtedly gout furnishes a larger number of instances where the 
complaint is found in both parents and children than any other disease of 
the same type and character, but by no means as frequently as a number 
of other diseases of whose heredity no one can doubt. We have already 
spoken of the true basis of heredity, and in making an estimate of gout's 
hereditary transmissibility we must remember these characters unless we 
wish to be misled. It is necessary also to think of the tendency of pa- 
tients to represent rheumatic or other articular affections as gout. This 
disease, too, is one that develops not in early life, the time we should ex- 
pect its manifestation if inheritance of function and tissue, and not merely 
habits of life, was the determining factor in making it manifest. On the 
other hand, gout is unquestionably a disease which is more influenced by 
habit and mode of life than almost any other, and which takes considerable 
time for the development of its effects. Again, hereditary gout, it is 
claimed, is frequently seen to skip a generation, and afflict the grand- 
child of a gouty grandparent. This fact, if substantiated, shows a very 
mild or doubtful kind of heredity, and the statement is quite as truly in- 
terpreted in another way, namely, that the gout of the grandchild was in 
reality acquired, his parent escaping by avoiding the habits of the grand- 
parent. 

The statistics on this question, as given by Scudamore, show that in 
58 cases out of 113, the disease was not known in any ancestor. " The 
cases of acquired gout, in which no family reference could be traced, were 



gout. . 253 

to the rest as 58 to 55 ; and in the examples contrasted with those imme- 
diately hereditary, as 58 to 44." Eleven cases of so-called heredity were 
in grandparents or more distant relatives. 

In the report of the commission of the French Academy of Medicine 
(1840), 34 out of 80 cases showed the hereditary predisposition. Garrod 
says, "That more than half the gouty subjects can distinctly trace their 
ailment to hereditary taint ; and if patients in the upper class of society 
are exclusively selected, the percentage is found to be considerably 
greater." 

Our opinions on the strength of the hereditary nature of the malady 
will vary with what we consider the essentials for the proof of its trans- 
missibility ; whether it depends on the transmission of function, or on the 
inheritance of habits and customs ; and also whether we demand more 
proof of this quality than is furnished by numbers. 

Customs and Nationality. — The occurrence of gout in certain nations, 
climates, and classes of people is a very striking feature of the ailment. 
The disease is rare among the natives of warm and moderate climates. 
This fact is strikingly seen in Europe, where the dwellers in the northern 
countries are almost the only sufferers. In England, the disease is more 
common, and has certainly attracted more attention than anywhere else. 
In Holland, and among the Scandinavian races it is also frequent. In this 
country the disease is not common, though by no means rare in its various 
manifestations, so that it is scarcely possible to contrast the differences in 
the various sections. 

The differences produced by habits of ease, rich foods and drinking, as 
well as by regular bodily exercise, are probably more striking than any 
other factors in causing the disease, but no one of these acting singly is 
sufficient for its development. 

The use of various kinds of liquors, and of a diet composed principally 
of meat, has been spoken of by many writers as though a proportional 
amount of gout existed potentially in each beverage or article of food. 
Unquestionably some of these are more potent than others in disordering 
the functions, and must be entirely avoided, or used in moderation by all 
who have suffered from the disease or by those who expect to escape its 
occurrence or repetition. Those distilled or fermented drinks, rich in 
alcohol and other ingredients, and food highly nitrogenized, are regarded 
as most likely to be baneful in their effects. 

Indigestion, whether directly traceable to improper articles of diet or 



254 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

arising from other causes, is frequent in gouty persons. It is not all forms 
of dyspepsia that are harmful, and certainly many patients suffer from 
this ailment all their lives without exhibiting any gouty tendencies. By 
many others the effects of hepatic congestion seen in many forms of diges- 
tive disturbance, especially when connected with congestion of the diges- 
tive tract, are strikingly potent in the production of gouty conditions. 
The state of the abdominal organs not unfrequently exists unaccompanied 
with symptoms which patients recognized as dyspeptic, and consequently 
the statement is often made that they have never felt the sensation of indi- 
gestion. 

Exhausted conditions, especially those connected with the nervous sys- 
tem, frequently determine an onset of the gouty paroxysm, but of late it 
has been doubted if any nervous condition alone was capable of develop- 
ing the disease. Cullen and his followers, however, looked to the ner- 
vous system as one of the prime causes of gout. 

Gout in many persons shows as great a predilection for certain seasons 
as does rheumatism, and in probably the majority of cases the initial out- 
burst comes at about the same time of year as do the attacks of acute 
rheumatism, and often for succeeding years the gouty inflammation re- 
turns at the same time that it made its appearance on the first occasion. 
As the morbid condition becomes established the attacks may return at 
quite irregular times and with greater frequency. 

Lead impregnation has for a long time been observed as a predispos- 
ing cause of gout. It of course especially occurs among those who work 
in some one of the many occupations in which this metal is used. We 
know the influence which lead poisoning has in affecting the mucous mem- 
brane of the digestive tract, and the conditions of these organs when thus 
affected are very similar to those of gouty patients, when the disease is 
due to other causes. 

Varieties. 

In dividing the groups of symptoms, as manifested in different patients 
for the purpose of study into varieties, it must be remembered that gout 
is essentially a time-lasting or chronic malady. It is the rarest of occur- 
rences to see a single paroxysm or a visceral phenomenon cease never to 
recur. It may not be so uncommon for a patient to be cured or for the 
results of the disease to become quiescent, but it is not until after the 



gout. 255 

paroxysms or other manifestations have been continued during a consid- 
erable period. 

The numerous divisions proposed by the older writers, though very 
expressive, tend to confusion, and their names form merely a list of the 
numerous principal symptoms and accidents to which the disease is 
liable. Without following up these minute ramifications, to which allu- 
sion is here made, gout is most usefully to be studied under the following 
heads : First, acute ; second, chronic gout ; and third, visceral mani- 
festations. To these must be added the condition of lithiasis or uri- 
ciemia. 

The divisions often overlap each other ; thus both acute and chronic 
gout may be attended with visceral lesions other than those of the joints, 
and the patient with chronic gout almost never escapes. The disease is 
hardly ever one of a single paroxysm, and therefore in the acute form we 
are in the midst of a chronic disease. The chronic form frequently has 
acute paroxysms. Visceral disease is rare without both chronic and acute 
articular phenomena. And none of the first three are supposed to exist 
without the latter being more or less constantly present, but the latter 
occurs, whether continuously or not we are not well informed, without 
any articular symptoms resulting, at least any of a marked character ; it 
is probable, however, that not unfrequently visceral lesions result from 
it, without at any time articular changes being presented. 

Another useful method of distinction is under the two heads of regular 
and irregular gout ; the former designates the articular malady, whether 
acute or chronic ; the latter is reserved for non-articular affections, both 
the lesions of internal organs, and those apparent acute inflammations which 
come in the chronic gout. The irregular class is somewhat vague in sig- 
nification and undefined in its boundaries, since it is in some respects 
uncertain whether any of the visceral manifestations occur without chro- 
nic, and often not specialized, lesions having preceded ; in other words 
whether an acute inflammation of the internal organ ever comes in this 
disease without a pre-existent chronic lesion being present. There is 
some objection to the words regular and irregular, on the ground that vis- 
ceral lesions are quite as frequently found post-mortem in gouty patients 
as have been the articular inflammations during life. These words, as 
commonly used, signify little more than internal and external gout. 
Nevertheless these terms serve often a useful purpose. 

The distinctions between these varieties can be given in the clearest 



256 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

manner by detailing their characteristics. Therefore we will proceed to 
consider their 

Symptoms, Cotjkse, and Duration. 

Until recently it has been the rule to speak of disease as developing 
suddenly in the form of an inflammation in or around one of the joints ; as 
though this inflammation were the initial stage of the disease. It is diffi- 
cult to believe that the morbid condition is thus sudden in its formation. 
Evidently the premonitory symptoms or conditions of gout are not to be 
come at from the feelings of the patients, for so many of them speak of 
perfect health and of unusual sensation of strength and good feeling, and 
for these reasons, as well as others, there are difficulties in obtaining oppor- 
tunities for the study of the condition. Other patients, however, com- 
plain of various dyspeptic conditions or unusual cardiac, respiratory, ner- 
vous or urinary sensations which, if they have suffered a previous gouty 
attack, they recognize as premonitory phenomena. 

In others, again, there is the complete absence of all prodromal symp- 
toms and the articular inflammation ushers in the attack. It is possible in 
these latter cases, if opportunities could be obtained for observation, that 
some clues, if not the complete solution might be derived, for in the other 
cases the dyspeptic and other phenomena do undoubtedly mask the un- 
derlying conditions not unfrequently. 

Acute Gout. — The attack is developed sharply and violently, usually in 
the latter part of the night, waking the patient from sleep with the severe 
pain in the affected joint. The pain is variously described by patients, 
but is always severe, more so, as a rule, than in acute rheumatism, al- 
though I have seen the rule reversed. " Screw up the vise as tightly as 
possible — you have rheumatism ; give it another turn, and that is gout," 
has been said of the relative amount of pain. In judging of the amount 
of pain it is well to bear in mind the condition and characteristic of the 
patient who is the sufferer. In gout there is often a very large element of 
irritability produced by the morbid condition itself directly, and to this 
must be added that the class of patients in whom gout occurs most fre- 
quently are not wont to bear discomforts patiently. In rheumatism 
neither of these circumstances concur. Pain is better borne by the poor 
man, as I have had opportunities of seeing, than by the man who acquired 
or promoted his gout with two or three bottles of port wine daily, with 
the surroundings which such luxury implies. The attention of the patient 



GOUT. 20i 

9 

can be more easily diverted from an inflamed gouty joint, than a rheu- 
matic inflammation. 

The metatarso-phalangeal joints are the favorite seat of the commence- 
ment of the attack, and its phenomena are most often confined to the sin- 
gle joint, especially in first attacks. The disease, however, does make its 
first appearance in other articulations, and may subsequently involve 
still others ; this is more frequently true of the chronic disease than of 
primary attacks. 

The affected joint, within a short time, becomes red and swollen ; the 
skin over it becomes more and more smoothed out and shining. The 
swollen parts either pit on pressure with an elastic feeling, or there is 
fluctuation from the fluid accumulating within the articular cavity. The 
veins over the joint or on the adjacent parts of the limb become conspic- 
uous from their enlarged size and dark purplish color ; the swelling often 
extends to the limb where the veins are affected, and here also there is pit- 
ting on pressure, but of a less elastic character. Spasmodic contractions 
of the muscles frequently add greatly to the pain. 

According to the severity of the local inflammation, there is a greater 
or less development of the general symptoms. Earely is there no fever, 
although in some cases it may be quite inconsiderable. The initial rigor 
is slight. The tongue becomes coated or is already furred or whitish. 
The bowels are confined. The urine is scanty and usually high-colored, 
depositing a sediment of reddish or pinkish urates or uric acid. 

During the course of the day following the nocturnal attack, the pain 
abates, especially if quiet and proper precaution have been observed. The 
inflamed joint, however, remains sensitive to touch or movements, and the 
general symptoms, as the local appearances, continue unchanged. 

As the second night approaches, or sometimes during it, an exacerba- 
tion takes place of all the symptoms, depriving the patient of sleep from 
then until about the same hour as the previous day, when a remission 
again occurs. The same succession occurs with as great or less violence 
during five or six successive nights, when the paroxysms commonly end. 

During the latter portion of this time, when the swelling has fully 
stretched the tissues, the nocturnal exacerbation are attended with less 
pain, the articular cavity is less distended, the fluctuation is more percep- 
tible, and the surrounding parts pit more distinctly under the finger ; the 
skin becomes wrinkled, and when the inflammation has completely sub- 
sided, desquamation takes place. 
17 



25$ RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Such is a typical attack of articular gout, which has been described so 
often, so graphically, and eloquently, made eloquent by personal suffering. 

The grade of the symptoms and the "variations in the joints affected 
are very considerable, although less in the latter respect than the former. 
/In a vastly greater number of cases it is the great toe joint, more fre- 
[ quently the left, which is alone affected than another ; sometimes other 
joints are invaded secondarily during a paroxysm ; again, this joint may 
never suffer either in the first or in subsequent attacks. Unlike rheuma- 
tism, the joints attacked do not appear to be those which are chiefly 
brought into severe functional activity, although traumatism does some- 
times appear to control the selection. I have, however, seen gout affect- 
ing only the finger in such persons, as penmen or tailors. Trousseau has 
described a form of gout — "gout of successive paroxysms" — which Char- 
cot has spoken of as acute primitive general gout. This form of the dis- 
ease invades many joints simultaneously, and its paroxysms are apt to be 
of longer duration. Charcot speaks of the great liabihty of mistaking the 
ailment for rheumatic polyarthritis. 

The general and local symptoms in some cases present but slightly 
pronounced characters ; this has been spoken of as asthenic gout. It oc- 
curs in the weak and debilitated, and is more common proportionally in 
women than men. There is very little fever, the swelling and redness are 
slight, but the ultimate changes or deformities are often just as marked 
as in severer cases. 

When the paroxysm ends, the patients describe themselves as feeling 
unusually well, better than before the attack ; this is especially true of 
those who have had marked symptoms during the pre-paroxysmal stage. 
After the primary attack, the function of the joint, in the vast majority of 
cases, is completely restored, but sometimes a considerable degree of 
swelling or stiffness, or both of these, remain for a period which may be- 
come indefinitely prolonged. In other rare cases, partial or complete 
anchylosis results, or concretions may form in the periarticular structures. 

As has been remarked, gout, even in its acute manifestations, is essen- 
tially a chronic disease, and after one paroxysm we are ever looking for a 
recurrence of an attack, or for the development of the chronic form of the 
disease, Or else some visceral lesions with their attendant symptoms. Usu- 
ally another onset of articular inflammation occurs, and the period of im- 
munity varies very greatly. The second attack rarely occurs sooner than 
the same season of the following year, in other cases it may be postponed 



gout. 259 

for two or three years, or even longer. In two or three of the next suc- 
ceeding paroxysms the interval may be equally long,. but afterward the 
attacks come twice a year, and finally at shorter and more irregular inter- 
vals, following no rule of time or season. The patient, unless measures 
have been rigidly enforced to remove the liability to the ailment, finds 
himself, with every indiscretion and even without apparent cause, on the 
brink of or in the midst of another attack. 

In the earlier paroxysms, the same succession of symptoms is shown 
during the attacks, with some remission of the sensation, and during the 
intervals the same complete restoration of health, both local and general. 

Later, the tendency is for more joints to become affected either pri- 
marily or subsequently during the paroxysm. Joints previously unaffected 
suffer, and the disease appears in the hands or knees or other joints. The 
general symptoms become of a subacute type. The intervals are shorter 
in duration, and during them there are nearly all the time either some ar- 
ticular symptoms or some of the many functional disturbances, directly 
connected with the morbid condition. The disease thus loses its acute 
form and becomes chronic. 

Chronic Gout. — Practically the chronic stage of the disease is charac- 
terized by the deposits or by the alterations which occur in or around the 
joints, as well as by lesions of the internal viscera which come in connec- 
tion with the disease. 

As has just been stated, the chronic form may arise through frequent 
repetition of acute paroxysms, and sometimes this condition may be 
brought about after a single particular attack by the maintenance of the 
functional disturbances which are so destructive to health. 

The chronic state is also characterized by general feebleness — and it is 
here difficult to draw a distinct line of demarkation — more or less marked, 
but which may amount to a positive cachectic condition. This feebleness 
tends rapidly to various organic degenerations, not unlike those usually 
seen in old age, but they often present characters distinctly gouty, and 
under these circumstances the disease most frequently makes rapid prog- 
ress. The organic changes are doubtless due to the constant condition 
in which the blood is found. 

Sometimes also gout exhibits the feebleness from the very start, and 
in these cases the visceral changes commence very early and rapidly ad- 
vance, and the deformities of the joints and the deposits in other parts of 
the integumentary surface are prompt in making their appearance. 



260 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The most important circumstance in chronic gout, in connection -with 
the articulations, is the deposit of concretion and the changes which they 
undergo, and the alterations which they induce in the form of the joints. 
After the deposits have formed they lead the existence of foreign bodies 
in the organism, but, like all foreign bodies, they, during all the stages of 
their formation and existence, give rise to active phenomena. During 
their formative stage the accumulating fluid produces soft fluctuating 
elevations of the skin. At this time there are rarely any changes to be 
witnessed except those directly connected with the gouty process, namely 
the further increase and the consolidation of the materials. I have seen a 
case, however, in which the accumulation of the semi-fluid matter took 
place so rapidly that the skin burst, allowing of the escape of the milk- 
white fluid ; the large subcutaneous vesicle collapsed and cicatrized with- 
out any purulent formation. Later, the hardened masses constantly give 
rise to inflammatory changes, and as constantly are added to by the 
farther deposits of the same material. They may encroach on the articu- 
lar structures, but more commonly the skin over them is destroyed, often 
without marked inflammatory changes, but also frequently by an ulcera- 
tive process. The destruction of the skin exposes the whitish deposit, 
and if any fluid material is present it drains away, or, if completely solid, 
it remains for an indefinite time and may be removed en bloc or undergo 
a gradual liquefaction through the process of ulceration. Kenewed at- 
tacks of gout, during this period, very constantly add to the amount of the 
deposited material. The ulcers or abscesses thus formed are very difficult 
to heal, and may remain open for long periods, without, however, causing 
marked general symptoms, or even any, and without exercising unfavor- 
able influence on the structures of the joint. Occasionally the subcu- 
taneous deposits extend deeply into the bone or cartilage, or are continu- 
ous with similar deposits in the latter structures, in which case the ulcer- 
ation leads to very great destruction and deformity when cicatrization is 
effected. 

Visceral Manifestations. 

In speaking of the symptoms, coming in connection with gout, which 
develop in other organs than the joints, it is necessary to be especially 
guarded. Formerly it was the universal custom to speak of many kinds of 
visceral changes as gout, even when no external symptoms had occurred. 
The expression " gouty " has been used to cover a multitude of errors. 



GOUT. 261 

In respect to the term " retrocedent " gout, it is clearly a misnomer 
and a misapprehension. First, gout is a constitutional malady, and there- 
fore must pervade the whole organism, and, besides, we cannot put our 
faith in any so-called metastatic phenomena. Secondly, a vast number of 
the symptoms ascribed to a gouty cause have, in reality, nothing directly 
to do with this malady. 

The real question is whether the symptoms and the organic lesions — 
and there are very many occurring in gouty subjects — are due to an actual 
invasion of the gouty inflammation, to functional changes coincident with 
the disease, or, in respect to the visceral lesions found post-mortem, to 
deposit of gouty matter in degenerating tissue altered by other morbid 
processes. 

It is unquestionably true that a genuine gouty process invades the vis- 
cera, or certain of their composite tissues, and this may occur in acute or 
chronic gout, or even may be seen in cases which have exhibited neither 
of these forms in connection with the articulations. The gouty process in 
these cases leaves its attestation behind it, which can be found post-mortem, 
either in the form of a deposit or of other changes, but these conditions 
are not numerous and are confined to very few of the organs. 

The quite numerous functional disturbances coming prior to, or in con- 
junction with, an attack of gout, are, in all probability — nay almost certainly 
— not gout. Some of them, for example the dyspeptic symptoms, may be 
looked upon, perhaps not strictly speaking, as the cause of, but rather as 
one of the foundations of the malady ; and the symptoms of a similar 
character which follow acute or chronic articular manifestations, while some 
of them may be due to gouty localizations, are in the great majority of in- 
stances the result of tissue alterations of a degenerative character, very 
similar to those seen in old age, but they certainly fail to attest their gouty 
nature by the appearances which they present. 

Every degeneration may, in a gouty subject, receive a special deposit of 
the gouty matters, and yet in these we fail to recognize their gouty origin 
from this fact alone. In the gouty subject whose blood is surcharged with 
uric acid, we could but expect that at least one of retrograde metamorphoses 
would lead to such deposits. Very many, if not all of the organic degen- 
eration observed in gouty patients belong to some one of the great general 
classes of tissue-changes, some of which are due to special causes, but the 
most of them own many causes ; one of these many causes can be, under 
certain circumstances, gout, but there is really nothing special in the 



262 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

appearances by which we can unequivocally pronounce them of gouty 
origin. 

The so-called functional derangements, on which so much reliance has 
been placed to prove the existence of visceral gout, are of course not purely 
functional ; they unquestionably rest on an anatomical basis, and yet the 
organ thus functionally disturbed, while not failing to show morbid 
changes, fails to show the connection of such changes. 

While such changes have been pointed to as gouty, no attempt has been 
made to prove them to be due to an invasion of the gouty inflammation, or 
at least the attempt has not been successful, unless in the case of one or 
perhaps two organs. Dependence has been placed chiefly on the succes- 
sion of symptoms ; for example, in the case of the stomach, disturbances 
which precede articular gout have been regarded as gout — instead of 
merely the cause of the malady — because the symptoms disappear from the 
stomach to manifest themselves in the joint. Such symptoms are very 
common in the stomach, and constantly lead to the same anatomical 
changes which are found in the gouty subject ; in one set of patients gouty 
inflammation of the joints never occurs, and neither are there any other 
symptoms which can be connected with this disease. Can we construe 
the anatomical alterations of the stomach as gout in such cases ? If we 
cannot consider them as gout in all cases we have naught to depend on to 
prove them in the gouty subjects. 

The so-called retrocedent gout of the stomach — derangements of its 
function coming after a gouty paroxysm, which are sometimes so severe as 
to cause death — shows nothing more definitely gouty than does the prece- 
dent form, except that the anatomical alterations are more advanced, so 
advanced that, after a violent or long-continued course of gout, their func- 
tion cannot be resumed to a degree compatible with continued life. 

In respect to other organs and the symptoms connected with them in 
gouty patients, the case is very much the same as with the stomach. In 
the respiratory tract acute inflammations are of rare occurrence, and do 
not seem to be connected with the gouty state. On the other hand, such 
chronic maladies as bronchitis and asthma are of very frequent occurrence, 
but not more so than in many other conditions ; moreover, their type and 
their symptoms are the same without the presence of gout. 

In former times the cerebral symptoms of this disease formed a very 
long list and occupied great attention. Gouty apoplexy is no longer con- 
sidered an attack of inflammation retrocedent to the brain ; it is a 



gout. 263 

cerebral hemorrhage from degenerated vessels which are present in pa- 
tients whose tissues are poorly nourished as is likely in gouty subjects. 

The habits of life productive of this disease favor the development of 
chronic headaches, but this form of suffering is not more common in the 
gouty than in others. Many other acute functional disturbances, such as 
delirium, are quite as well accounted for by chronic alcoholism as by 
gout. Acute alcoholism and excessive venery both have among their 
rarer symptoms certain forms of spinal j^aralysis, which have been charged 
to the account of acute and chronic gout. 

The liver must necessarily be changed in all subjects whose digestion 
is disturbed in the manner common to all those who acquire gout by 
the most usual cause ; in those who suffer from it by heredity or who 
do not indulge in excessive drinking the organ is much less affected. 
The lesion is not as frequently as we might suppose a cirrhotic contrac- 
tion, but more especially atrophic changes of the liver-cells. But of the 
liver — the chief organ concerned in the production of uric acid — we know 
less than of almost any other organ, and are less well able to explain 
physiological and morbid states of activity. 

The urinary organs, chiefly the kidney, suffer not only chronically but 
also directly and acutely, from the effects of gout. The changes are apart 
from those due to calculous formations which are exceedingly common. 
It seems not surprising that the kidneys, and even other parts of the uri- 
nary tract, should suffer in this disease, since these organs form the prin- 
cipal outlet of the excessive morbid matter present in the blood in this 
malady. The inflammation of the joints are not to be regarded as the 
summa of the disease, but rather as a local trouble incited by the pres- 
ence of the uric acid. The other organs of the body may occasionally, as 
we have seen, be disturbed by its influence, but in general to a very slight 
degree. The kidneys, however, do, as we should expect, present evidences 
of both acute and chronic manifestation of the gouty process. 

It is probably an exaggeration to speak of any functional disturbances 
of the organ as metastatic alternations between the kidneys and the joints. 
In acute gout their function may become disturbed, as it does sometimes 
in other acute diseases, for example, the continued fevers, but we do not 
in these cases speak of typhoid or other fevers of the kidney, neither 
should we in the case of gout. When the kidney is invaded by the in- 
flammation of the gouty process, the organ responds with symptoms some- 
what similar to those seen in nephritis of various forms due to other causes. 



264 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

The character and severity of the symptoms vary, as in other cases, with 
these causes and the mode of their application. The lesions in the kidney 
form one of the members of a well-marked group in Bright's disease ; it 
is one of the forms of contracting kidney. In addition to this the effects 
of the gouty process leave the attestation behind them of deposits of urate 
of soda. 

In the heart we never see such changes and symptoms as result from 
attacks of acute rheumatism. The functional derangements commonly 
alluded to in gouty subjects are palpitation and certain irregularities of 
the pulse ; but these are frequent in many forms of disturbed digestion 
and in other conditions, and therefore are in all probability dependent on 
the same cause in all these maladies. The fatal cases formerly attributed 
to retrocession of the disease to the heart are probably all to be explained 
by cardiac failure due to fatty degeneration of the muscular fibres. In 
chronic gout this condition is not unfrequent and is owing to the general 
poor nutrition, the tendency to fatty changes and accumulations in all 
parts so frequently seen, and perhaps also to the overaction of the heart 
from constant stimulation ; the condition is more common at all events 
among those whose potations have been free and abundant. 

I have taken the ground denying the existence j)f most of the so-called 
localizations of the disease in the internal organs which have been so fre- 
quently and freely assumed by most observers, because of the almost com- 
plete failure to signalize the present or the results of the gouty process 
by anatomical evidences. Not a few careful observers, with wide experi- 
ence, have assumed the same position ; the majority have, however, seen fit 
to coincide with the older opinions on the subject, and to-day a large num- 
ber of conditions, whose pathology is unexplained, are classed under the 
manifestations of latent gout. One of the principal reasons for this classi- 
fication is the therapeutic test, or rather the therapeutic failure which has 
attended the measures applied to combat the symptoms. 

Pathology and Morbid Anatomy. 

The views of the nature of gout and the theory of the disease are 
to-day dominated by the presence of the uric acid and its salts, which 
play so prominent a part in the phenomena of the malady. It is almost 
the only disease in which the existence of the apparent materies morbi 
has been shown with clearness, and its presence is so very unequivocal 



gout. 265 

that it is quite impossible to escape from it in the discussion of the theory 
of gout. The evidence is everywhere and always complete in favor of its 
development in the blood and tissues in every instance of the malady. 
The question arises, however, whether in certain morbid conditions this 
material, which is a normal excrementitious matter in limited quantities, 
may not be present in an abnormal quantity, and even form deposits, and 
yet no such trains of symptoms to which the name gout has been applied 
result. 

While the presence of the uric compounds is unquestioned, the theory 
of gout must account for their presence from retention or from their de- 
velopment in increased quantity, or by both of these factors. In other 
words, the consideration of the nature of gout concerns itself almost en- 
tirely with the process set in motion, by which an abnormal quantity of 
morbid matter finds itself within the organism, and only secondarily with 
the effects of this matter on the various tissues and functions. 

The ancient writers declared that there was a morbid matter in the 
blood — and this to them was true of all diseases — and pointed to the ar- 
ticular deposits in proof of the truth of their assertion. Hence, with the 
products of the disease in hand, their views of the nature of gout, as gath- 
ered from their writings, seem much more definite and positive, whatever 
may be said of their accuracy, than for other diseases. They were, how- 
ever, unacquainted with the nature of this material, and it was not until 
the end of last century that its chemical composition was recognized. 

After this time it was by nearly all spoken of as the morbid matter, 
but its presence in the blood was not shown until Garrod, in 1848, carried 
out his investigations. As the result of these investigations it became evi- 
dent that the amount of uric compounds removed through the kidneys 
lessened during the attacks of the disease ; that uric acid was present in 
the blood in all cases of gout, as was shown by the causing it to crystallize 
from the serum, and that there was a deposit in the articular tissue of 
this matter, even in first attacks of gout. 

" It must not, however, be supposed," says Garrod, " that an excess of 
urate of soda in the blood constitutes gout ; " but still no physiological 
theory has been until quite recently attempted to account for the disease. 
And every question in relation to the malady has revolved about the in- 
crease of the quantity of this material, and the disease remains par excel- 
lence the poison-disease of our present nosological catalogues. This poison 
was by them supposed to be effected almost entirely by the ingestion of 



266 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

various articles of diet which were capable of being converted into uric 
acid. 

The questions then to be considered, if we attempt to formulate a 
physiological theory, are, first, Is there an increased production of uric 
acid ; is it due to ingested matters which interfere with digestion, and which 
either before absorption or afterward by failure of assimilation increase 
the amount of this product ? Second, Is there simply a' retention of the 
normal product of the system, which, as in the former case, acts to disturb 
its functional activity, and set in motion the morbid train of symptoms. 
Or third, Is there a process set up wholly within the organism, whose ac- 
tion is favored or promoted by the character and quality of the food and 
by the general mode of life. 

There is little or no evidence to support the speculation that the in- 
crease of the uric compounds is due to the failure of renal excretion. "We 
know of no condition of the kidney in the antecedent period of gout 
which lends the support of facts, and we do know, moreover, of diseases 
of these organs causing retention of this material in which no gouty phe- 
nomena are recorded. 

In respect to the origin of uric acid and its excess in the blood in 
gout, the theories of it have been very similar to those of lactic acid in 
rheumatism, and the older theories of both have passed through the same 
transformations and alterations of their terminology in recent times. 
Formerly it was supposed, and this was especially insisted on by Todd, 
that uric acid was derived from an abnormal condition of the stomach and 
duodenum. Todd, however, did not consider that uric acid was essential 
to gout, but included along with the uric compounds many other ma- 
terials as the offending matter. 

As in rheumatism, so now in gout, according to more recent physi- 
ological teaching, the uric acid is derived from errors in the secondary, 
rather than primary 7 , processes of assimilation. Some look to the failure 
of the oxidation of the albuminoid materials of the food, which ordinarily 
are converted in part into urea, as the cause of accumulation of the uric 
acid. Others direct attention to certain organs, as, for example, the spleen, 
which when enlarged, as in leukaemia, give rise to increased amount of 
this substance. It has also been sought to trace it to the joint structures, 
the cartilages, and fibrous tissues, in which after gouty attacks the deposits 
are first seen. 

But at present our knowledge of the physiological and pathological 



gout. 267 

chemistry of the formation of uric acid and urea, their relations to each 
other, their relation also to the ingesta, on the one hand, and to the meta- 
morphosis of tissue on the other hand, is so imperfect that no satisfactory 
theory can be formulated. 

Of the third speculative question suggested above, there is nothing as 
yet been suggested which supports it. And in absence of a knowledge of 
the life history of uric acid, I do not see on what grounds we can proceed 
in its discussion. Following the analogy of all other morbid processes it 
seems but rational to think of a misdirected function as the basis of the 
gout, and that also the production of the morbid material is the result of 
an excessive activity of the process by which uric acid is normally manufac- 
tured in the system. I speak thus of the presence of uric acid because it 
is so constantly present, but it does not seem unlikely that gouty symp- 
toms may occur without uric acid, and also that uric acid may be present 
in excessive quantities without gout. It would, therefore, seem that there 
must be some underlying process which is the essential of the disease, 
which is apart from, or at least only a part of, the process which produces 
uric acid. On the whole, therefore, it would seem that we know more of 
the results or products of gout, and less of its essential nature, than of 
almost any other disease. In some respects we seem to know more of its 
essential cause, and can produce or reproduce its train of symptoms — in 
other words, produce the misdirection of function which leads to it with 
greater certainty than in most other diseases of the same class. 

The post-mortem history of gout concerns itself almost entirely with a 
description of the uric acid deposits, the changes which they induce, and 
the situations in which they may be found. We have therefore mostly to 
do with the joint structures, for it is almost exclusively in and around 
them that the deposits occur. Besides this, there are various changes 
found in the internal organs, but these are so inconstant that no particu- 
lar description is needed further than the allusions already made. 

It has been shown by a number of observers that the crystals of urate 
of soda form in the articular cartilages of the affected joints, and, as Gar- 
rod says, they are present from the very first attack, gradually increasing 
as the attacks are repeated and the ailment becomes chronic. The de- 
posits persist indefinitely even should the attack never be repeated. The 
seat of the earliest deposit is shown to be the superficial layers and 
around the centre of their free surface. The surface of the cartilage 
shows a white patch. It has been suggested that this position is one 



268 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

most remote from the vascular area of the articular tissues. Finally, 
however, the whole cartilages are invaded, and, in the chronic stages, the 
synovial membrane and the ligaments become incrusted with chalky- 
material. 

The concretions, or tophi, which are found around the joints, and 
which sometimes, though rarely, occur early, or even at once, after first 
attacks, or in purely chronic cases, but nearly always later on, after fre- 
quently repeated attacks, form in the bursse, along the tendons, or simply 
in the connective-tissue interspaces. In their very earliest state they con- 
sist of fluid more or less richly impregnated with uric acid compounds, 
which, from their deficient solubility, crystallize in the form, when it is 
urate of soda, of acicular crystals. I have tapped such swelling with a fine 
needle, or examined exudation from such swellings, which have opened 
spontaneously, and found the milky fluid composed of a clear serum in 
which floated innumerable needle -like crystalline masses ; besides these, 
there were a few large and small granular corpuscles, similar to those 
seen in any serous fluid. 

Later, these fluid collections inspissate, and finally become often ex- 
ceedingly hard and dry. In this stage -the tophi, as well as the deposits 
in the cartilage or other places, sometimes fail to show their crystalline 
character, but present a confused opaque agglomeration of the same ma- 
terial, which, by proper chemical agents, can be made to assume its t}^- 
cal appearance, or can be converted into uric acid. 

These concretions have been found in a number of other places besides 
the usual one around the joints. They have been described in the bony 
tissues, and not unfrequently in the periosteum. The skin in various parts 
of the body, generally the legs or thighs, probably arising from deposits in 
veins passing near veins from and around the affected joints. The cartilages, 
or skin covering the ears, is a very common seat of their occurrence, and 
here they may serve a useful purpose in clinical investigations of doubtful 
cases. The eyelids, the nose, the cheeks, and along the tendinous struct- 
ures of the palms of the hands, where they produce sometimes the char- 
acteristic contraction of one or more fingers (Dupuytren's contraction), 
also exhibit their presence. Virchow speaks of a concretion in the larynx, 
one record has been made of them in the lungs, and Charcot mentions 
the penis. Even the spinal dura mater and spinal nerve-roots receive 
incrustations of uric acid compounds. 

The concretions are also found in the kidney, as sometimes rounded 



GOUT. 2 GO 

masses in the cortical substance, but more commonly as streaks or points 
extending along the straight tubes as they ascend from the medulla into 
the cortex, and also at the summit of the pyramids. In the specimens 
which I have seen, the deposit was almost intertubular, and it was seen in 
the region of the convoluted tubes as well as the pyramid portion of the 
organ. The kidneys usually exhibit a more or less advanced stage of in- 
terstitial nephritis (contracting kidney) in cases of chronic gout, while in 
the early stages the records indicate that little or no changes are visible. 

Diagnosis. 

The recognition of a joint inflamed with gout is nearly always a simple 
matter, and it is only in the cases where unusual joints or a large number 
of them become involved simultaneously, as in acute general gout, that 
the diagnosis is difficult to make. 

In gout the small joints are usually alone affected ; the febrile disturb- 
ance is moderate ; the sweating not profuse. The joints present a differ- 
ent appearance, which has already been described. The habits and mode 
of life generally furnish a useful clue to the nature of the malady, but it 
must be remembered that there is a poor man's gout as well as a rich 
man's — one might say almost a starvation as well as a repletion gout. 

The serum of the blood, according to Garrod's investigation, furnishes 
us an infallible test when gout is well developed. The fluid from a blister, 
and probably, also, from the subcutaneous connective tissue drawn by a 
needle, serve equally well for the purposes of Garrod's thread test. 

The chronic varieties of the disease are much more difficult to distin- 
guish from other maladies. The presence of tophaceous deposits around 
the joints, and in the other situations already mentioned, will often serve a 
useful purpose. 

The various functional disturbances, which have been discussed among 
the symptoms of the disease, furnish in themselves very little evidence of 
their nature, and without the presence of external deposits must be re- 
garded as doubtful. On the other hand, the functional disturbances con- 
nected with obscure articular symptoms are often sufficient to make clear 
the character of the latter. 

The lithsemic condition, with its vertigo and mental symptoms, its 
heartburn and eructations, is revealed when sufficiently careful, and per- 
haps continued, examinations of the urine are carried out. 



270 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

Prognosis. 

The outlook for a gouty patient is hardly ever favorable. The malady 
probably never causes death in its early or acute stages. One attack of 
gout is so constantly followed by others, and by many repetitions, that a 
chronic condition with its attendant discomforts and dangers is induced. 
However, many patients suffer from frequently repeated attacks, and even 
severe ones, and yet in the intervals maintain a very good state of general 
health and live long lives ; some even become free from the gouty parox- 
ysms and remain in good health. More commonly, however, the course of 
the disease is ever a downward one, and may be cut short at any period 
by the rapidly coming organic degenerations, or by many of the accidental 
intercurrent maladies to which these patients seem especially liable. 

The prognosis of the hereditary form of the disease would appear to 
be less favorable than of the acquired malady, and is also perhaps — and 
this is the reason of its unfavorable tendency — more liable to visceral al- 
terations. 

Prevention by a rigid course of life and of diet seems to have more in- 
fluence, or perhaps this is more easy to carry out with those who have 
acquired gout than with those whose ancestors have suffered from its dis- 
turbances. 

The more limited the acute manifestations, and the more strictly they 
are confined to single joints, the better is the prospect of preventing 
renewed attacks, or without this, of living to an old age. The earlier 
in life gout makes its appearance the more unfavorable is it for the sub- 
ject. 

Garrod says that "if the urine was formerly turbid with urates, or if it 
gave rise to a deposit of crystallized uric acid, and has become of late clear 
and of a paler color, the change probably indicates that the kidneys have 
to a considerable extent lost their power of eliminating uric acid, and that 
which seems to the patient a favorable change is in reality a sign of seri- 
ous structural alteration in an important secreting organ." "It is a grave 
sign in gout to find the urine pale, the specific gravity exceedingly low, 
and the fluid devoid of uric acid ; and if, in addition to this condition, 
albumen is likewise present, the indication becomes still more unfavor- 
able." 



GOUT. 271 



TREATMENT. 



The treatment of gout presents itself to our consideration under sev- 
eral heads. First, the institution of measures to prevent the development 
or continuation of the malady ; second, the remedial measure in an acute 
paroxysm ; and third, in the stage of chronic gout. 

Too much stress cannot be placed on the enforcement of a proper mode 
of life, avoiding the conditions which have been described as so constantly 
prevailing in the habits of gouty persons. Whatever may be the views on 
the production of uric acid, whether due to the improper conversion of 
the albuminous matters, or whether this sort of diet prejudices certain 
organs or processes engaged in producing this material, it is certain that 
no medicinal agents will be effective in removing, or even checking, the 
perverted turn which the organic processes have received or acquired. 

What the measures are which must be enforced has to be decided for 
each patient, and reference must also be had to the time of life and the 
stages of the malady. It must be remembered that starvation measures 
are nearly, not quite, as disadvantageous as the opposite of this extreme. 
A mixture of food is unquestionably what is required, and the vegetables, 
toward which the diet list must be mostly directed, should not be of the 
bulky or watery sort, and the meats must be of lighter, easily digested 
kinds. Fats and oils, and articles or meats containing them, eggs, pota- 
toes, and most of the farinaceous articles, and tea and coffee, strong or in 
large quantity, must be avoided. 

In regard to the number and times of taking food, it requires most care- 
ful management ; some do better with more than the usual three meals, 
others can, to their advantage and greater comfort, be restricted to less than 
the ordinary ones. The heavier meal should come early in the day, and 
this is often best effected by a full breakfast early in the morning. 

The gouty patient must be warmly clothed. How many of the chronic 
cases suffer from more or less constant pains, which ought to be avoided 
by attention to this simple matter ! How many, too, of old gouty patients 
exhaust their strength in warm weather, or in warm rooms, sweltering 
from the heat of extra wraps ! Both sets of patients have their theories 
and prejudicies in regard to clothing and temperature, which are exceed- 
ingly hard to overcome. 

Clothing suited to the circumstances is the most useful adjuvant we 
have to exercise in promoting the activity of function not only of the skin 



272 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

but of other organs, and should always be superintended with great 
care. 

Exercise, which by its activity is suited to prevent a gouty development 
and to promote healthy digestion, as well as to consume certain elements, 
especially the fatty ones, which are necessarily present in more or less 
amount in the diet, is quite unsuited to chronic gout with its visceral and 
articular complications. And where active muscular exertion is impossi- 
ble it should be replaced by passive movements and other measures help- 
ing to promote a proper circulation of the blood. 

The various forms of special diet treatments is useful often not only in 
themselves, but frequently as a means of regulating the dietary, which pa- 
tients so frequently transgress when merely general directions are given. 
Often, too, these special diets and cures can only be carried out in certain 
countries, which by their salubrious climate and attractive scenery are of 
benefit to the patient. Of these the grape and whey cures serve as good 
illustrations. 

Probably the successful treatment of gout in any of its numerous forms 
and stages can never be profitably carried out without the aid of some one, 
or even many, of the natural or artificial mineral waters. Ordinary chink- 
ing water is often found very useful, and is too often omitted from the 
dietary list of these patients. The natural mineral waters are of course 
much more valuable than their artificial imitations, and when it can be 
done, they are much better taken at the springs. 

The waters serve many useful purposes. As purgatives of a thorough 
yet unirritating, undisturbing character, they may always be used, and 
constipation is at nearly all stages of the disease a difficulty which requires 
careful management. In addition to this, many waters serve to relieve the 
catarrhal conditions of the stomach and bowels, which must be allayed be- 
fore any improvement in the gouty tendency is effected — if these conditions 
even do not stand as a cause of the disease. This improvement effected, 
the tendency to an increased production of uric acid is lessened or re- 
moved. Further, the use of water is essential in promoting or maintaining 
the solution of the uric acid. Pure drinking waters contribute to this, but 
there is a greatly increased efficacy afforded by many of the salts contained 
in the natural mineral waters. This effect we may consider serviceable 
during all stages of gout, both before the threatening paroxysms and 
after them if required, as well as after deposits have formed, although 
it may be regarded as doubtful whether anything will affect these concre- 



gout. 273 

tions ; sometimes they may gradually lessen if the process of accretion is 
stopped. 

Probably no disease has had more infallible remedies proposed to its 
cure than gout. The quack remedies in themselves form an innumerable 
host, the old ones passing away and new ones taking their places. 

The alkalies and alkaline salts have always enjoyed a high reputation in 
the disease, and were used as a remedy for its acidity long before the 
presence and the nature of uric acid were pointed out. Theoretically 
much has been said in favor of one or other of two common alkalies over the 
other ; but both of them, under certain circumstances, exercise a very bene- 
ficial influence. I have always thought that their disadvantageous effects 
were greater on stomach digestion than their ultimate effect on the blood, 
and it is on account of the former rather than the latter that their exhibi- 
tion has to be discontinued. Of their neutralizing action, and the conse- 
quent benefits, there is, however, no doubt. 

Better in its effects, and apparently without the disadvantageous effects 
of the former alkalies, is lithium and its salts. The existence of this alkali 
has been known for many years, but only recently has it been introduced 
into the list of drugs for this disease. It is very common to find it in the 
natural mineral waters along with the other alkalies. Taken in this form, 
it too, like the other natural salts, produces its best effects ; but it is very 
common to administer it — and it is very useful in this way — in the form of 
a carbonate. The combination of lithium with uric acid forms the most 
soluble of all the urates. 

Treatment op the Paroxysm. 

We know pretty well that a paroxysm of typical character will end, un- 
influenced by remedies, if unprejudiced by wrong regimen, within a few 
days. This at least is the rule in typical cases, and knowing this fact a 
gouty inflammation presents itself to us as a morbid process which re- 
covers more rapidly than any other of equal severity. We know of no 
other inflammation which passes away so soon, whatever may be its treat- 
ment. It is a question, therefore, whether it is not better to stand by 
with watchful care than to interfere actively. The results of active treat- 
ment, especially local measures, are known in many cases to be harmful. 

Nevertheless it is not proper, whatever may be our theoretical or prac- 
tical conclusions, to do nothing during the continuance of an acute attack. 
18 



27 ± RHEUMATISM, GOUT, AJSD ALLIED DISORDERS. 

This is especially true in the earlier paroxysms, occurring in healthy per- 
sons, although it is sometimes best to follow the do-nothing policy in the 
milder paroxysms of chronic gout, and especially in those patients in whom 
we know that there exists visceral degenerations or lesions. In the latter 
class all our procedures should be of the most guarded character. 

There is one drug, and it is perhaps the only one, which has at any 
time maintained the character of a specific for gout. It is colchicum, and 
it should be given in an acute paroxysm, whenever there are not pretty cer- 
tain contra-indications to its use, such as known irritability of the digestive 
organs, fatty or other lesions of the heart, or kidney disease, and perhaps 
other less common concomitants of gout. In almost every primary at- 
tack, and many of the earlier ones, its exhibition may be made with freedom 
in proper doses. Its effects are usually good and pretty prompt, and when 
otherwise it not only does no good in the paroxysm, but its general and 
ultimate influence on the patient is harmful. 

The more chronic the disease 'and the further advanced the visceral 
changes, the less useful is colchicum, and the more carefully watched must 
be its administration. There are three results to be especially guarded 
against, its purgative and otherwise disturbing effects on the digestive or- 
gans, the disturbances on the nervous system, and its depressing effects on 
the circulation. 

Combined with this drug it is often well to administer moderate doses 
of the alkalies, either as carbonates or in combination with some of the 
vegetable acids ; these may be given as effervescing draughts, and this 
form is applicable to the nausea and vomiting often present. These salts 
can be made to serve at the same time as purgatives, diuretics, or diapho- 
retics. 

The local measures, as has been said, are not essential to recovery, but 
it is well to try and mitigate the suffering when intense. It is necessary to 
remember the character of the inflammation with which we have to deal, 
an inflammation in which the tendency to suppuration never has to be 
combated, and also one which, if we may speak so, runs a regular rapid 
course to recovery if not disturbed. It is the comfort of the patient and 
the after-results of the local disturbance which require attention, and 
hardly at all the violence of the inflammation. 

If the inflammation does not tend to run its regular course we cannot 
force it to do so by violence, but only direct or persuade it by the assist- 
ance of gentle means. Such is its natural history. In order to abate the 



GOUT. IWO 

inflammation when violent, we do not require bleeding or cold, but the 
soothing influence of heat and moisture, and these two must be proportioned 
to the severity of inflammatory process. Combined with these the ano- 
dyne lotions are of great service. 

"When the inflammation lingers, slight stimulation is of use, carried out 
by means of blisters and similar agents, proportioned in strength to the 
result desired. It is probable that the effect of stimulation, especially ves- 
ication, is due to the influence exerted on the circulation of the part rather 
than to the removal of irritating fluid by the serum. Blisters and even 
moxse or cautery have been employed to check or abort the gouty inflam- 
mation, and in some cases it is reported very successfully. The ultimate 
effects on the articulation cannot but be bad. Although these agents may 
check the inflammation, the cicatrization resulting from them places the 
joint in a very unfavorable condition on the renewal of the gouty parox- 
ysms, even if its immediate effects do not become unfortunate by indu- 
cing sloughing, etc. 

Treatment of Chronic Gout. 

" Colchicum is found equally efficacious in subduing the exacerbations 
in chronic gout as in combating the early fits in the acute disease, due re- 
gard being paid to the strength of the patient, and dose regulated accord- 
ingly," says Garrod. 

There seems to be a pretty general consent given to this statement ; 
but the limitations imposed on its use by the dangers to the chronic, en- 
feebled, gouty patient, are such that many have completely abandoned its 
use under all circumstances. The drug does much to relieve the pain and 
inflammation in the chronic stage, though probably less effective than in 
the earlier attacks ; but in its use we are brought face to face with dangers 
which it is almost impossible to recognize or foresee. If these dangers 
are recognized, colchicum must not be prescribed, or else immediately 
abandoned. There are other methods of controlling the inflammation and 
preventing to a great degree further danger to the articulations by the 
long continuance of a paroxysm without resorting to this oftentimes dan- 
gerous remedy. 

The use of alkalies, as already described, will here serve a good pur- 
pose, and be in reality of more service than in the earlier attacks, and at 
the same time free from danger. Another remedy is guaiacum, bjit its 



1?76 RHEUMATISM, GOUT, AND ALLIED DISORDERS. 

immediate effects are but slight during an acute attack. It is serviceable 
for the purely chronic cases, or when the articular inflammation tends to 
remain long or become continuous, assuming a subacute type. 

The various iodides, especially iodide of potash, are used to produce 
the well-known effects of these compounds, and they are also recom- 
mended for their influence in controlling the inflammation. This latter 
effect is somewhat doubtful, except in its very low grades, and their influ- 
ence on the special uric acid deposit is unproved. 

The vegetable tonics and bitters are not merely useful, but frequently 
quite essential to the gouty subject. None of them appear to exercise any 
director specific action on the gouty process ; but in connection with other 
remedies, and in assisting and maintaining the digestive functions is 
where they show their best effects. Cinchona in its various forms and 
preparations has long been used, and it is thought by some to diminish 
the quantity of uric acid excreted, by the kidney. This drug is recom- 
mended in combination with colchicum, and it is also prescribed along 
with gentian. The latter has also been extensively used both alone and 
with the bicarbonates of the alkalies. A tea or decoction of common ash 
has long been known as a household remedy for gouty subjects, and the 
list of preparations taken from the trees and plants of different localities 
and countries forms a very extensive one. 

In addition to the various medicinal agents here spoken of, and very 
many more, the treatment of chronic gout must be supplemented by the 
adoption of a most careful mode of life, habits of eating and of exercise, 
and by the use of many of the agents spoken of under the prevention of 
the disease, such as mineral water and baths. 



INDEX. 



Acid, lactic, origin of, in rheumatism, 56 
lactic, theory of, with rheumatism, 

51 
salicylic, in acute rheumatism, 208 
action of, in acute rheumatism, 215 
uric, in the urine in rheumatism, 116 
Aconite in acute rheumatism, 198 
Age in etiology of gout, 251 

in etiology of rheumatism, 22 
Albumen in the urine in rheumatism, 102 
Albuminuria secondary in rheumatism, 

104 
Alkalies in acute rheumatism, 198 
Anatomy, morbid, of rheumatism, 153 
Anaesthetics, local use of, in acute rheu- 
matism, 219 
Angina, rheumatic, 134 
Antimony in acute rheumatism, 198 
Arthritis, acute rheumatic, differentiated 
from acute rheumatism, 178 



Bladder, condition of, in rheumatism, 

105 
Blisters in acute rheumatism, 192 
Blood changes in rheumatism, 156 
Brain, acute inflammatory affections of, in 

rheumatism, 138 
Bronchitis in rheumatism, 134, 135 



Cartilages, articular condition of, in 

rheumatism, 155 
Cephalalgia, rheumatic, 148 
Cerebral rheumatism, 141 
Chill a symptom of rheumatism, 68. 83 



Chronic articular rheumatism, 222 
Cinchona bark in acute rheumatism, 194 
Climate in etiology of rheumatism, o2 
Colchicum in acute rheumatism, 194 
Complications of rheumatism, 120 

nervous, 137 
Counter-irritants in acute rheumatism, 

192 
Customs in etiology of gout, 253 



Death from cardiac and other complica- 
tions in rheumatism, 181 
from violence of the fever, 180 
Delirium as a symptom m rheumatism, 

74 
Diet in acute rheumatism, 220 
Digestion in rheumatism, 74 
Digestive organs in rheumatism, 136 
Disability from joint changes in rheuma* 

tism, 183 
Diuretics in rheumatism, 189 
Drugs in etiology of rheumatism, 41 



Embolism in rheumatism, 168 

a cause of secondary albuminuria in 
rheumatism, 104 
Endocarditis, rheumatic, 124 

histological process in rheumatism, 
164 

morbid anatomy of, 160 

symptoms, 127 

chronic rheumatic, 172 
Epistaxis in rheumatism, 75 
Eruptions of rheumatism, 9S, 99 



INDEX. 



Face, aspect of, in rheuinati-m, 72 
Fever a symptom, of rheumatism, 69, 82 
death from the violence of, 180 



Gi-NITO-urinary apparatus in rheuma- 
tism, 101 
Gonorrheal rheumatism, 240 

differential diagnosis from acute ar- 
ticular rheumatism, 177 
Gout, acute, 250 
diagnosis, 269 
differentiated from acute rheumatism, 

178 
etiology, 251 

pathology and morbid anatomy, 204 
prognosis, 270 

retrocedent, of the stomach, 262 
tophi in, 268 

symptoms, course, and duration, 250 
treatment of, 271 

of the paroxysm, 273 
varieties, 254 

visceral manifestations, 260 
Chronic symptoms of, 259 
treatment of, 275 
Guaiacum ia acute rheumatism, 194 



Hemorrhages of rheumatism, 99 
Heredity in etiology of gout, 252 

in etiology of rheumatism, 16 
llyperinosis in rheumatism, 153 
Hyperpyrexia in rheumatism, 138, 144, 
15 7 



Joints, affection of, in rheumatism com- 
pared with gout, 92 
condition of, in acute rheumatism, 



Joints, relation to cardiac and other com- 
plications in rheumatism, 93 
temperature of, in acute rheumatism. 
93 



Kidneys, question of rheumatic localiza- 
tion in, 101 



Lancereaux's interstitial nephritis in 

rheumatism, 103 
Lemon-juice in acute rheurn.-itisin, 2Ui 
Localizations, extra-articular, of rheuma- 
tism, 120 

Menses, state of, in rheumatism, 74 
Mercury in acute rheumatism, 198 
Metastasis in rheumatism, 94 
Muimurs, cardiac, in rheumatism, 168 
Myocarditis, rheumatic, 124 
acute and chronic, 174 

Nationality in etiology of gout, 253 
Nephritis, Lancereaux's interstitial, in 
rheumatism, 103 
Payer's rheumatic, 103 
Nomenclature of rheumatism, 11 

Occupation in etiology of rheumatism, 

37 
Opium in acute rheumatism, 197 
Orchitis, rheumatic, 105 
Ovaries in lheumatism, 105 

Pain a symptom of rheumatism, 70 

cause, seat, and character of, in the 
joints in rheumatism, 89 

Palpitation, nervous, in rheumatism, 147 

Pathology of rheumatism, 42 

Pericarditis, rheumatic, 124 
symptoms, 127, 173 

Pleurisy, rheumatic, 132 



duration of affection of, in rheuma- 
tism. 93 

morbid anatomy of, in rheumatism, j 

154 | Pneumonia, rheumatic, 133 

numeiical frequency in the different, Potash, bicarbonate of, in acute rheu 
93 1 matism, 200 



INDEX. 



279 



Potash, bromide of, in acute rheumatism, 
202 
citrate of, in acute rheumatism, 201 
nitrate of, in acute rheumatism, 199 
Predisposition to rheumatism, 184 
Tulsa in rheumatism, 73 
Purgatives in rheumatism, 188 
Purpura embolic of rheumatism, 99 
Pysemia, differential diagnosis of, from 
rheumatism, 177 

Quinine in acute rheumatism, 195 



Race in etiology of rheumatism, 82 
Raver's rheumatic nephritis, 103 
Redness of the joints in acute rheuma- 
tism, DO 
Regimen in acute rheumatism, 220 
Respiration, humid, in rheumatism, 147 
Revulsions in acute rheumatism, 192 
Rheumatism, acute : 

affection of the genito-uiinary ap- 
paratus in, 101 

affection of the kidneys in, 102, 1C3 

alkaline treatment, 198 

bladder, urethra, ovaries, uterus, and 
testicles in, 105 

bronchitis in, 134 

cardiac murmurs in, 168 

causes, 16 

cerebral, 141 

chill of, 83 

classification of varieties, 10 

complications, 120 

condition of bladder in, 105 

condition of the joints in. 88 

condition of the skin in, 95 

course, duration, and severity of, 75 

definition, 7 

description and course of the disease, 
67 

diagnosis and prognosis of, 176 

digestive organs in, 136 

embolism in. 168 

endocarditis in, 124, 127 

eruptions of, 98 



I Rheumatism, etiology, 2 

fever of, 82 

forms of, 8 

hemorrhages of, 99 

history of, 2 

intercurrence of Bright's disease with, 
103 

liability to second attacks, 183 

morbid anatomy of, 153 

myocarditis in, 124 

nervous complications of, 137 

nomenclature of, 11 

nosology, 2 

pathology of, 42 

pericarditis in, 124, 127 

pneumonia in, 133 

pleurisy in, 132 

preclispositicn to, 184 

prognosis of, 180 

salicyl treatment, 205 

sweating in, 96 

synonyms, 7 

temperature in, 84 

treatment of, 185 

urine in, 107 
; Rheumatism, chronic articular, 2-22 

diagnosis, 229 

morbid anatomy, 227 

symptoms and course, 225 

treatment, 230 
Rheumatism, gonorrhoeal, 240 

symptoms, course, and results, 243 

treatment, 246 
Rheumatism, subacute, 76 

its distinction from other grades and 
forms, 80 



Salicylate of soda in acute rheumatism, 
209 
action of, 216 
Salicin in acute rheumatism, 205 

action of, 210 
Salicylic acid in acute rheuraat : sm, 208 

action of, 215 
Salicyl treatment, mode of action in acute 
rheumatism, 210 



2S0 



INDEX. 



Seasons in etiology of rheumatism, P4 
Sex in etiology of gout, 251 

in etiology of rheumatism, 27 
Skin, condition of, in rheumatism, 73, 95 
Sleep in rheumatism, 74 

in etiology of rheumatism, 38 
Soda, salicylate of, in acute rheumatism, 
209 

action of, 216 
Stomach, retrocedent gout of, 262 
Sudamina in rheumatism, 98 
Sudorifics in rheumatism, 190 
Sugar in the urine in rheumatism, 178 
Sweating, its significance in rheumatism, 

96 
Swelling of the joints in acute rheuma- 
tism, 91 



Temperament in etiology of rheumatism, 

38 
Temperature in rheumatism, 73, 84 

of the joints in rheumatism, 92 
Theory of rheumatism, 42 

the electric, 46 

the infection, 64 

the inflammatory, 43 

the lactic-acid, 51 

the nervous, 46 



Theory, the spinal, 47 
the vascular, 45 
the vaso-motor, 50 

Tophi of gout, 268 



Urea in the urine in rheumatism, 114 
Urethra, condition of, in rheumatism. l0< r 
Urine in rheumatism, 74. 107 

albumen in, 118 

color of, in rheumatism, 110 

density of, 113 

fibrinous, of rheumatism, 118 

reaction of, 112 

sugar in, 118 

uric acid in, in rheumatism. 116 
Urticaria in rheumatism, 98 
Uterus in rheumatism, 105 



Vegetations, valvular, in rheumatism, 

170 
Venesection in rheumatism, 186 
Veratria in acute rheumatism, 198 
Vertigo, rheumatic, 148 
Visceral manifestations of gout, 260 

Woollens, application of, in rheumatism. 
190 




OCT 1953 



